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0 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 Olt (Complete in Triplicate) Appllcatlon 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f� ��,,� �� Job Address 7 Al Ja l_9::12Ar I�-C3 `City-1. ��15 Lot size/Acreage ZQGCG Owner's NameC/2�� Address 95 '7 /V/��L'K VDRL' r`-c� .Phone - - 3 C' tractor � O (r Addresse0 �O-C 9arXfI-F License No.�3Sa. 7� Phone- MDQ' TYPE OF WELL/PUMP: NEW WELLpJ' WELL REPLACEMENTX DESTRUCTION Out of Service Well ❑ -1 PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 1190 SEWER LINES DISPOSAL FLD. PROP. LINE-30 FOUNDATION AGRICULTURE WELL �i&L OTHER WELL PITS/SUMPS 12X INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Irtduttnal X Open Bonom ❑ Manteca Dia. of Well Excavation p Dia. of Well Casing D col/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1��'e��w...'AAA-////qqq Specifications 19!Public �❑1 Other fl Delta Depth of Grout Seal _ TV q o1 rout I 1 Irrigation Approx. Depth I Eastern urface Seel Installed by iii 2.L ( p( „G Rspow Work DOM ❑ Type of Pump M.P. St IW k Don Destruction X WON Diameter Sealing Material A Depth 7 11 Vu Depth /L/J'� Filler Material L Depth - - -w) TPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo saplic system permitted if public saws, is available within 200 leet.l �rtatallNion will waw: Residence_ Commercial_ Other of living units: _ Number of bedrooms haracler of wN to a depth of 3 feet: Water table depth BE TANK ❑ Type/Mfg Capacity No. Compartments Pf G. TREATMENT PLT.❑ Method of Disposal .I Distance to nearest: Well Foundation Propeny Line I, CHINO LINE ❑ No. g Length of lines Total length/size FILTER BED ❑ Distance to Maroc: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that I hew 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 County Morns 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 employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or tub-contracting signature Cerllfiee the following:'9 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's Compensa- tion law of Colifanla." The applicant must not for ON required ins coons. Complete drawing ort trreverse side, ^-D Sip �d /V / /AnL�/1/Lhd1C�f\ Title: fit"- Date: �c FOR DEPARTMENT USE ONLY Application Accepted bynA_PV:�W t k - Date �� 1L AreaO7 PM or Grout Inspection by ate Z'12- 132 Final Inspection by � Date �' 1 !J Additional Comments: C/ p D r. ' aAdditionalComments: JP /�ozy(�ei) Applicant - Return al cops to San Joaquin County Public Health Services Environmental Health permit/Seryl eek l 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 II PJf /YV�I/ ��yyy INFO AMOUNT DUE AMOUNT REMITTED CKAH RECEIVED BY DATE PERMIT NO. Q�, . EN t}S41REV.I I a s, wO 1 1 ,00 q r�-0 O � — ?07 00 EM 14>♦