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t APPLICATION FOR PERISIT u SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUINs PHONE ( 209 ) 468- 3420 OX TON , CA 201 PERMIT BEXPIRES 9I YEAR gFROM DATEISSUEDFILE COPY ( Complete in Triplicate ) Application is hereby taada to Ban Joaquin County for a permit to construct and/ or install the work herein described , Thee application is made in ceegtllance with Ban Joaquin go^uq Ordinance No . 549 and 1862 and the Rules and Regulations of Sec Joaquin County Public Health Beryl pt l moln '-kirl ) �W- CIIs ��/a Job Address n 14nl * , J Wmh FA 71t'CC-`t City Lot Size/Acreage p / owner's Name ARco {�rodw. bi CaMDontA Address Q ,BOX �U � � Phone _ 1 1 f x Conti actor � A1�OLT � �' I1 � Address License�J 1?S�X 3.OJ(v License No..Lt11 Yd?1—_ Phone TYPE OF WELL/ PUMP: W WELL Z WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTE REPAIR C1 - 'gOTTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK C'L_J_ SEWER LINES N DISPOSAL FLut7� PROP. LINEALLL FOUNDATION AGRICULTURE WELL OTHER WELL PITS / SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � + Ll Industrial ❑ Open Bottom ❑ Manteca Die . of Well ExcavvationiFgd Dia . of Well Casing2 r),,k ( 1 Domeatic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing _ 1 UL Specifications 1 ' I Public (:1 Other Il Delta Depth of Grout SealType of Grout _ I I Inivatlon _ Approx, Depth 1 I Eastern Surface Saul Installed by Dif I � e ✓ Repair Work Done ❑ Type of Pump H . P . State Work Done Well Destruction O Wall Diameter Sealing Material A Depth Depth Piller Material i Depth i TYPE OF SEPTIC WORK : NEW INSTALLATION I I REPAIR / ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sawar is available within 200 feet. ) Installation will "me: Residence _ Commercial _ Other i Number of living units: _ Number of bedrooms character of GOA to a depth of 3 fest: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation _ Property Line t . i J n LEACHING LINE Cl No, A Length of lines _ Total length/size FILTER BED Cl Distance to nearest: Well Foundation Propeny Line 1, ytA SEEPAGE PITS 11 Depth Size Number / ( SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, bud � j l rules and regulations of the Sen Joaquin County Homes owner or licensed agent's signature cenif es the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California . " Contractor's hiring or sub-contracting ugnmoe conifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's comµsnss tion laws of Cafifornla." C� The spplkant st all for NI te 1 led Inspections. Complete drawing on reverse aid�y r� tni SignedTitle : �� /� / Date: On Seln> Rc0 FOR DEPARTMENT USE ONLY y/ Application Acoapted by Date / Area (� �j/ ° ._ Pit or Grout Inspection by Date rys� Final Inspection by �to Additional Comments: �— Applicant - Retuft all copies to : Ban Joaquin County Public Ilealth Services Environmental flealth Per+blt /Servlcea 445 N San Joaquin , P O Box 2009 , SLkn , OA 95201 FEE f, 1 NFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED By DATE PERMIT NO. i . EN 13 34 lalV. + inn+ //1 / U1 -- _ / !/Ly/ �� yZ ( lW /✓ � r EN 14 m / W�w