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APPLICATION SAN AQUIN COUNTY PUBLIC HE Trb,4 ENVIRONMENTAL HEALTH DI ISION 445 N SAN JOAQUIN, PHONE (2 93420 P O BOX 2009, STOCKTON, A 2 1 DECZ PERMIT EXPIRES 1 YRAP FR M AS u (Complete in Triplic to V # PERMIT/SERVICES Application is hereby made to San Joaquin County for a permit to construct an or na a uorere n s application is made in coopliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regul.atipns of San Joaquin County Public Health Services. Job Address 2' a 6� /✓C J04,0AI�� Cl' te y ✓��l`-_L__ _ Lot Size/Acreage Owner's Name /'0ST 1� I/ ICARs -Z;41<f Address 2-041ar � ,rit4O4D� Pfione��—��! / � I.�L.��?3�v s, SARATaGi9-S�c�✓�//3/6 .P� ContractorADV19,tk'E Dkir A14 Address ?!9.PATGA /'Q 4 74 License fro. ,Z Pnoe� -- 02.5 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION 0 Out of Service Weil. ❑ PUMP INSTALLATION C SYSTEM REPAIR C' OTHER Q Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINESDISPOSAL FLO.N/A-_ PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ALli INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation '/ Dia. of Well Casing 2 Domestic/Private AGravel Pack ITracy Type of Casing__yr � _ Specifications�liilT,,,.. C1 Public l`1 Other 1-1 Delta Depth of Grout Seal fir. Type of Grout,64i-Ar 4f4fE,✓ I I Imilation Approx, Depth I I Eastern Surface Sedl Installed by AD✓/9,/L-0 tJD I/l,A G, S'O Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material Z Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ' I REPAIR/ADDITION i I DESTRUCTION l I INo septic syslem permitted if public sewer is / available within 200 feet.! Installation will serve: Residence_ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation property Line LEACHING LINE 0 No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Founaat,on Property Line SEEPAGE PITS i I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 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 Nome 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 subktCt to workmen's compensation laws of California." Contractor's hiring of subcontracting signature certifies the following: "I certify 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 for all required inspections. Complete drawing an reverse side. ]� _ Signed X Title: i /S /1"M1 Date: 12 _3 73 �1J✓i4�✓CF So%L ECN s o � , 'gleX k q g5,9 FO DEPAATMEf4T USE ONLY o ` Application Accepted by Date / } �I Area Pit or Grout Inspection by--m ` _a Date S l Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 5�o1 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 a� INFO FEE AMOUNT Dt1E AMOUNT REMITTED CASHCK 41 By OAT( PERMiT't�it7. EH,3.7.,REV.tinsi oo -'' aQS ,� to /f-3 EN EN 14.20 (� ;�^_