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APPLICATION FOR PERMIT ; SAN u, AQUIN COUNTY PUBLIC HEALTH . . RVICES 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 llade , to San Joaquin County for a permit to construct and/or install the work herein described . This application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Countyy./.Public Health ,-Services . a 1 /, j�� Job Address 7ft & ' r .r Cl LE�2a0 5771�-T,q City QS ' z` kkh Lot Size/Acreage Owner's Name R (wo P+0L1 r r, AddressV / - /Phone Contractor r � / Address R, (2 �k� ��4&q License No Phone Phone TYPE OF WELL/ PUMP : NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of 9erviee Well ❑ PUMP INSTALLATI�O� N� �/yy❑ SYSTEM REPAIR ❑ - OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK VA7 SEWER LINES L Sd DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ./..T.D - PITS / SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing 2 hL n Domestic/ Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications I ' 1 Public Cl Other tbelta Depth of Grout Seal Type of Grout - 11 Irrigation — Approx. Depth I I Eastern Surface Seal Installed h , /7 � F✓s Repair Work Done ❑ Type of Pump H , P, State Work Done _ i Well Destruction ❑ Well Diameter Sealing Material Depth Depth Piller Notarial a Depth TYPE OF SEPTIC WORK : NEW INSTALLATION I I REPAIR /ADDITION I I DESTRUCTION I 1 INo septic system permisewer is available within :♦�t . Installation will "me: Residence _ Commercial _ Other p�C� �V Q Number of living units: _ Number of bedrooms Character of sog to a depth of 3 feet: Water tablel�,yy��yyv 992 IYV SEPTIC TANK . ❑ Type/Mfg Capacity No. Co toiiNTY PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Lt"Vji �L HEALTH DI llblull LEACHING LINE ❑ No. 8 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 prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Couaty Homs 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 shell not employ any person in such manner as to become subject to workman's compensation laws of California . " Contractor's hiring or subcontracting signature certifies the following: 4*1 cartity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa. tion laws of Calilor ' The applicant at II aqu' spsctions. Complete drawing on ;reverse side. �1 Signed Title: f ✓-� 4N4Date: / Z FOR DEPARTMENT USE ONLY 9 Application Accepted by Date 0 �L Area A �� Z Final Inspection Pit or Grout Inspection by Date pe b �� Doy to Additional Comments: `� y 9Z- J / `WZ/, 19 9;1�� n5 fes!`"' u . Applicant - Re n all copies to : an Joaquin County Public Health Services Environmental Health Permit/ Services 445 N San Joaquin , P 0 Box 2009 , Stkn , CA 95201 FEE AMOUNT DUE AMOUNT REMITTED Ck RECEIVED Sy DATE PERMIT% N�a I O CASH /� n J-1 . EH t}N IREV. 1 / nal 7L !�/�liLl N9 , S FH lx�aa f ffCC// '