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APPLICATION FOR PERMIT SAN -JAQUIN COUNTY PUBLIC HEALTH -=riRVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby mede,to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance Be. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. '�/ ('J i� f" i i Job Address ""� CCuv:7'Y"V C.i,�' LNf� _ City�ICIC`'�`6A- Lot Size/Acreage ICC X IwZC Loc C Owner's Neme�t/kc�/L r` US:I L't C.�Vt{3 Cf. Address SC.v� r"%A.fi� '"l hone G(D ,,-7 f cit CH-i ij: s FH✓ ( p Contlacltw C 'q l.t Address Cc.�cc✓:A C ✓ License No 3 i Z Phone 67t—�3d7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �If O ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation -+-�-C-S Dia. of Well Casing 1 ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ �>v (" Specifications W I'I Public ❑ Other n Delta Depth of Grout Seal ^� Type of Grout 1nkk!tA CGwk,vT I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permtied it public sewer is available within 200 loot.) Installation will verve: Residence _ Commerclal _ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have preparec this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of IM Sen Joaquin County \ Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not (((lp\I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I unity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman"e compenss tion laws of California.- The applicant must call for MI requ/}k]edins p ctiopa. Complete drawing on reverse side. q e, Signed - f"^�" Title: Pvc t_CT : S f Dote: FOR DEPARTMENT USE ONLY Application Accepted by _I Q Date L ` y Area Q Pit or Grout Inspection by �^"'^^`' pate 3-Yz Final Inspection by Dale Additional Commence: / � Applicant - Return all copies to: San Joaqu County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stan, CA 95201 KI INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMR'N0. E ,s z.uEv ,.si 315 9�/��z gL5zd� E1CM-