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APPLICATION &aq{ pq PEWP St', UkbAN JOAQUIN COUNTY PUBLIC TEAT THrTA, W :3 3 1 3 y P.O. Box f:02 • Lirdan, CA 95[3 13 ENVIRONMENTAL HEALTH DIVISI }y Phone (209; '44-g9.gg 445 N SAN JOAQUIN, PHONE (209)4 _ J State Lic. R 5;:ff•:::; P 0 BOX 2009, STOCXTON, CA 9 PERMIT EXPIRES 1 YEAH FROM DTE �',p� a' (Complete in Triplicate) �(JL/ Applicatlem in hereby made to Sen Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County PPu�blJi�c Health rvicee. Al ([�'� /e Job Address � "� C� ril otl City QC To It., Lot Size/AcreageAk�^ /�.�{ Owner's Name �� Address lga l< Phone -J.�s •t+-� ContractorT ?][ 'ddresso&.T&)1 A46r 'License Na. Phone .6y TYPE OF WELL/PUM : NEW WELLWELL REPLACEMENT 11 DESTRUCTION ❑ Out or Service Ve12 ❑ PUMP INSTALLATION A SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr L] Industrial ❑ Open Bottom Ci Manleca Dia. of Wall Excavaliion_ Jor. Dis, of Well Casing Domestic/Private k L1va Gravel Pack Tracy Type of Casing_J vl. C IV Specifications I'I Public 1:1 Other P Delta Depth of Grout Seal r T pe of Grout I I titillation __Approx. Depth I I Eantann SrAace Seal Installed by Repair Work Dona ❑ Type of Pump SIA& H,P. 2_''t .__— State Work Done _ Wall Destruction O Well Diameter Sealing Material a Depth Depth Filler Material d Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 200 Iast.I Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of MR to a depth of 3 fast: Water table depth SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation_ Property Lina PMME►ET �'77T7R LEACHING LINE ❑ No. 6 Length of lines _ Total Iengt FILTER BED ❑ Distance to nearest: Well Foundation _ Pr % t SEEPAGE PITS 11 Depth _Size Numh SUMPS LI Distance to reszast: Well FoundationPIl"**Bl1A#THSFRVICFR DISPOSAL PONDS ❑ ENVIRONMENTAL HEALTH DIVIS0 I hereby cavity that I have prepared this application and that the work wilf be done in accordance with San Joaquin county ordinances, state laws, and roles and regulatiorts of the San Joaquin County Hems owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit Is Issued, 1 shall not employ any person in such manna as to become subject to workman's compensation laws of California," Contractor's hiring or subcontracting signature sanies the following: "1 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's comWnw- tion laws of C ifornfa." i The applicant st cell for quir P ins tions. Complete drawing rwersa side. . C Signed '� Title:�aeril . 1 _ Date: J r FOR DEPARTMENT USE ONLY Application Accepted byDae JS? ��AArrea Z Pit o ou Impaction by Date a (Final Inspection by ""` Date Additional Comments: - � � +yt1 - fit �1 / �� urn ©�D�all copil O San Joaquin narent County Public Health Servic "L410 OEM es , W �n �:�/„ " 19 Eavlroameatal Health Permit/Services X01- Ire +�� I r 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 4J 6 ` FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, Q NFO H R ti. taEv.crest ER 4CA . is-at