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~� APPLICATION FOR PERMIT SAN QAQUIN COUNTY- PUBLIC HEALTH VICES 'ENVIRONMENTAL HEALTH DIVISION 4455 SAN JOAQUIN, PHONE (209)4683420 P O BO% 2009, STOCSTON, CA 95201 PERMIT FIRES„l YEAR FROM DATE IgSUED (Complete in Triplicate) Application 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 Ord1hance No. 549 and 1862 and the.Rule a and Regulatione of San Joaquin County Public Health Services. Job Address -20-0._ `�"y City Lot Size/Acreages I Owner's Name 1 Qa '"? Address Phone' .�t1/' 1� Z . Contractor �� 2t Address 1 "w• t i n Licensrr'Flo. �T9 Phone 1q�1(0 373 11 TYPE OF WELLIPUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION'❑ Out of Service well 0 tori well PUMP INSTALLATION SYSTEM REPAIR ❑ ��O��THHyyERVS#jj C] DISTANCE 70 NEAREST: SEPTIC'TANK SEWER LINES DISPOSAL FLD>y PROP. LINE FOUNDATION” AGRICULTURE WELL 2_Q_ OTHER WEL PITS/SUMPS ZZ) �"t+ INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA IONS L) Industrial 0 Open Bottom C-Manteca Dia..of Well Excavation Dia. of Well Casin Cl Oomastic/Private 0 Gravel Pacwk C Tracy Type of Casing_ �' Specifications 1"1 Public 1�Other (� r Delta Depth of Grout Seal 3S' Type of Grou I I Ifrigation _.Approx. Depth I I.Easter Surface Saul Installed by& Repair Work Done U Type of Pump H.P. State Work Done ; Well Destruction 0 Well Diameter Sealing Material i Depth Q Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DESTRUCTION I t:INo septic system permitted it public sawer is available within 200 feet) Installation wiu serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of aoa to a depth of 3 feet: Water table depth SEPTIC TANK. p Type/MfgCapacity No. Compartments �� PKG. TREATMENT PLT.0 Method of Disposal S Diatance to nearest: Well Foundation ;Property Line (� LEACHING LINE Cl No. 6 Length of lines. Total length/size FILTER BED 0 Distance to nearest;. Well Foundation . Property Line SEEPAGE PITS l I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lays,.and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "! certify that in the performance of:the work for which this permit is jawed, E shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or suit-contracting signature certifies 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 laws of California." The appoAn!_musl cast forequifed inspections. Complete drawinj onn reverse side. 0 u"l - �} Z Signed X Title F� � ' " "7'� Date FOR DEPARTMENT USE ONLY: / Q Application Accepted by // F� Date C L Area Pit or Grout Inspection by�' Date`P L Final Inspection by Additional Comments: �Grii f Applicant - Return all copies to: San Joaquin County Public Health Services Nnvironmental Health Permit/Services j 445 N Saa Joaquin, P O Box 2008, Stkn, CA 95201 r� IEE �`� INFO AMOUNT DUE AMOUNT REM177E0 CASH RECEIVED BY DATE gPERMIT*NO. /^ . EM 13-24 IRty.,i h 51 EM 14•76 (p