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APPLICATION FOR PERMIT SAN jOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I T r „ - .1Oslot Size/Acreage / X f Job Address ��}- c "i+'.y "City J i 11 Owner's Noma \• �• tel>;a. l�iJf� ti 2s(.(-b C`Addrers ..�till C, Cc..:i.:C �s....a„ S,,. R�asL:C"moo 4� /c' �rc .�� ,ate, , Co„C,.J C �c)r �)—�7 Contractor i�t�•�t�co Z'l Addressl/0_35 0, C�•rc'r-•A fly+ License No. 434343 Phone 77 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Yell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ Cr?>c%T ,}, OTHER )Z Monitoring Yell gyp/ 1N, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSALKLD. PROP. LINE `/(� �I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J/ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation > Dia. o1 Well Casing Cl Domestic/Private wrovei Pack ❑ Tracy Type of Casing_ Specifications —7 I"1 Public Cl Other fl Deni.a Depth of Grout Seal '� /S Type of Grout yW�-I I I Irrrylalion 3-6 Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Wall Diameter Sealing Material i Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feel.) Installation will sena: Residence _ Commercial _ Other Number of Irving units: _ Number of bedrooms Choracter of will to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. CompartIPA PKG. TREATMENT PLT. ❑ Method of Dir MsaI Distance to nearest: Well Foundation Property Lina L• FIVE ri LEACHING LINE ❑ No. g Length of lines Total length/size E� FILTER BED ❑ Distance to restart Well Foundation Property Line SAN JOAQUIN COUNTY Jl PCBtTCREALTH SERVICES SEEPAGE PITS 11 Depth Sire Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 7 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state levet, and rules and reguletwm of me San Joaquin County Home owner or licensed agent's signature conifer, the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any parson in such manner as to become wblect to workman's compensation lows of California." Contractor's hiring or subcontracting signsture certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to worknun's compensa- tion laws of California." (� The applicant must call for all required inspections. Complete drawing on reverse side. C/— Signed / p Signed L L. -I�1..1-ct.�� Title J EG�E:T ��Lc��L'�TS i Date: /— FOR DEPARTMENT USE ONLY 1 Application Accepted by Date �� Area 3� `- 9-z �Iz 9-� Pit or Grout Inspection by Date�j-1 final Inspection by 1- Dau <`! Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services O l Environmental Health Permit/Services O oV 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOVNT(y�D}VE AMOUNT REMITTED CASH RECEI ED BY GATE PER 7 N EN I}N IaFV.,inmt /I X'✓/ 7�/�_92 �1 -,311 EN v.a V Ll