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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 0 BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �j 67. 066 -t 'g (Complete in Triplicate) Application Is hereby sleds to San Joaquin County for a permit to construct and/or install the work herein described. This application Is made in compliance with San Joaquin County Ordinance No. 49 and 1 and the Rules and Regulations of San Joaquin County PublicRech Services. `2 O 0 "V-A Y rQ-0 L" Job Address D, P-ee-�r/SFS �V`�*11 r- City c'n Lot Size/Acreage - t p ] )) Owner's Nomen M� Al Il Sf>'r1 � , 2rAddre�ss 1 a,-)7cs� 0a X S Yi'L/D IN Conti aclor va / v Address RD nc1'%L1Va &/T License Noa9q-3 Phona3 8-09-77 TYPE OF WELL/PUMP: NEW WELIL�K WELL REPLACEMENT F DESTRUCTION D Out of Service Well D PUMP INSTALLATIONX SYSTEM REPAIR D OTHER O Monitoring Well LJ DISTANCE TO NEAREST: SEPTIC TANK las SEWER LINES DISPOSAL FLD. PROP. LINE 3-_ o ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS/�O N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \� D Industrial Xopen Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing >(Domsstic/Private D Gravel Pack O Tracy Type of Casing_ 8N y Specification I Public 1-1 0 her fl Delta Depth of Grout Seal © Type of out smolt �, I I Irrigation ^ `7r O - ��Appox. Oc�ptA (L�1 I Eastern Surface Sea, Installed by � Y.y !'.] !L/ �h n G Repair Work Done D Type of Pump �.2.eA) H.P. J 0, State Work Done S A<- A-, .PC Well Destruction O Well Diameter Sealing Material a Depth NOT'-Y Ass Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION 11 (No septic system permitted it public sewer is available within 200 feat) _ Installation will serve: Residence_ Commercial_ Other (� Number of living units: _ Number of bedrooms Character of wil to a depth of 3 feet Water table depth G SEPTIC TANK O Type/Mfg Capacity No. Compartments -- PKG. TREATMENT PLL D Method of Disposal Distance to nearest: Well Foundation Property Line _ LEACHING LINE Cl No. d Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Lina SEEPAGE PITS 11 Depth Size Number v - SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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, and rules and regulations of the San Joaquin County Home 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 subcontracting signature cenifiss the following: "I comity 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 California." The applicant must call Jor MI requir,ed/inspeotlone. Complete drawing on reverse sed ..y Sig i,9 AIL4 �J'y� Title: C, t"-G V /.J�'-5 � Date: I FOR DEPARTMENT USE ONLY l Application Accepted by - Date Ani* 2 •N _ Pit or 9�lp Inspection by -J�n1e� Date 93 Final Inspection by I Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ✓ Environmental Health Permit/Services _. 445 N San Joaquin, P O Box 2009, Stich, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE PERMIT NO. J Oa q3 3 -/i,s- iMU-HIREV.rr.li 13 27b / G�22� —EN,4.ze / �3