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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION • 445 N SAN JOAQUIN, PHONE (209)468-3420 iLG,fa P 0 BOX 2009, STOC%TON, CA 95201 /4 �� Y PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r �.J f 3 y o (Complete in Triplicate) 1r Application is hereby made to San Joaquin County for a permit to construct and/or Install the work herein described. This application 11 ride in coopliance with Ban Joaquin County Ordinance No. 549 and 1862 kind the Rule. and Regulations of San Joaquin County Public Health Services. Job Address 6 u [ city nn�/( SfLI �/tT� Si ze/Acre2geof _ Ownar's Name !t Address • L . Jl&dA4" Phone a �j r Contractor ' ._Address License No.�1 9 Phone_M70_� 2- TYPE OF WELLIPUMP. NEW WELL C WELL REPLACEMENT F DESTRUCTION ❑ Out o1 Service Well D PUMP INSTALLATION OSYSTEM REPAIR C OTHER 0 Monitoring Well 0 DISTANCE TO NEAREST; SEPTIC TANK _ SEW LINES DISPOSAL FLO. PROP. LINE __ FOUNDATION - AGRIC LTURE WE OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA STRUCTION SPECIFICATIONS D Industrial Cl Open Bottom G Manteca Die. of Well Excavation- Die. of Well Casing 0 Oornestic/Private 0 Gravel Pack L1 Tracy pe of Casing__ Specilications VI Public (I Other fl Delta 0 th of Grout Seal Type of Grout - I I Iragat,on _Approx. Depth I I tarn Su ce Soul Installed by ' Repair Work Done ❑ Type of Pump H.P. __� Stats Work Dons _ Well Destruction O Well Diameter Sealing Mater i Depth - �geptfi Filler 14fterial A Depth TYPE OF SEPTIC RK: NEW INS TA LLATIO REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted it public s8wer is �p available.within 206 fes1.1 �J\ Installation will serve: R encs =--Commercial_ Other Number of living unhs: � ,Number oP badr Character of sail to a depth of 3 feat: _ V Water table depth SEPTIC TANK 0 Type/Mfg Il CAPscity No. Compertrrteinto PKG. TREATMENT PLT.0 /A o 6 d nMethod Distance td Wep �O Founds ion lop Property Line n , LEACHING LINE D No. a Length of lines _ ., T))a��,,a��l length/size We FILTER BED D Distance to harvest: Well oundetfon.1,0/! Property Lina SEEPAGE PITS I I Depth 41 Size mbar. SUMPS LI Distance to riasi Well oundshon� Property Line DISPOSAL PONDS D I hereby citrtily that I has prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate lewf, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I cattily that in the performance of the work foe which this normal is issued. I shell not employ any person in such manner as to become subject to workman's compensation Iowa of California." Contracla's hiring or sub-contracting signature candies the hosowkp:"I certify that in the parto(monte of the work for which this permit is issued, I sham employ persons subject to workman a compinse Non laws of California." The applicant must c for all regjped1inspectian Compels drawing on reverse aids. - Sprtad Title- Date: J�PR DEPARTMENT USE ONLY Application Accepted by --�At`..+a�I— ,�� Dale Aret(�i� it r Grout Inspection by'fi_Zs�. /-�9 eta�1�5'i�z._, Final Inspection by DateB.LII.�..� • Additional Co intemr: G D'T— Applicant - Return all copies to: San Joaquin County Public Health Services 5^ DODO r--3 / g.vl roamental Health Permit/Servs Can K �(QW 445 N San Joaquin, P 0 Box 2009, Stkn, CA 0520 L NFAMOUNT DUE AMOUNT REMITTED Ck RECEIVED BY DATE PERMIT NO.En 13-Ss IaEV..r x 5IA / // r r ! 9?S. / 0 EH 14M TTT' Iij�eq LS