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APPLICATION F R PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1601 E. HAZELTON AVE. ; HONE (209)468-3420 - -- P O BOX 2009, S TON, CA 95201 REMIX EXPIRES 1 YEAR FRPM D (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to cimstruct and/or install t2ie irork herein described.- .This application is made in cottrpliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of-San Joaquin County Public Health Services. Job Address co/ .Soa'rff VFKr4Z4 _ City -s-r mi ; Lot Sia/Acreage RzrPr, Owner's Name AteT44 he#,fc #,4 7,etrA7 Address -100 er I aclt4r., af4010 Phone- `f1 - 14 - 06Pf 50ec To�2k4 S! 2-6 . ... -Contractor:_:__ _�rkt��f'�.oR4*r�1 " Address 2g�-1=. � c.>< S7- License No: - � Phone 4 -"p-f+ TYPE OF WELL/PUMP:_ _ ., NEW WELL _ WELL REPLAC MENT ❑ DESTRUCTION ❑ Out of Service Ye11 ❑ PUMP INSTALLATION ❑ SYSTEM EPAIR ❑ OTHER O ,—,.Monitoringg Fen:C DISTANCE TO NEAREST:"SEPTIC TANK '`� - "-SEWER LINE'S !"0 � DISPOSAL FLD."-NA PROP. LINE—1� --•'-== FOUNDATION 3S AGRICULTURE WELL NS A OTHER WELL Io PITS/SUMPS :NAI INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU TION SPECIFICATIONS 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel Excavation I z" Dia.-of will Casing-f" 6d Dom2p rc - . ...Specifications Mc arn1l'1 Publia�ncy�p 6�1 Other rion,ree,;,5 R Delta depth of G out Seal �' r Type of Gra N ► �J f I I Irrigation 1L.Approx. Depth I I Eastam Surface Se I Insialled by': SyeaTG.LM I�vt_1>rt;!?_.►,___ Repair Work Done .0 Type of Pump H.P_ State Work Done Well Destruction ❑ Well Diameter `t Sealing Material 6 Depth R"•Fon;4-r. Depth 30' _.._ Filler Material i Dcpth ->x iz S.}„d ,,e c 1,vs t - g - - TYPE OF SEPTIC WORK: NEW INSTALLATION II I - REPAIR/ADDITION I I- D STRUCTION 1.1 (No septic stem P Y permitted it publicsewer is, available within 200 feet.] Installation will serve: Residence Commercial Other _ _- - --- _ Number of living units: Number of bedrooms z. �I Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK. ❑ Type/Mfg Cap 3city No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 'f LEACHING LINE_ ❑ No. & Length of lines Total le_ngth/size ! FILTER BED ❑ Distance to nearest: Well Foundation Property Line ASEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances,,state lacus, 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,1 shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the followings "I certify that in the performance of the work for which this pe rmit is issued,1 shall employ persons subject to workman's convanss- tion laws of California_,. The applicant must call for al required inspections. Complete drawing on reverse side. Signed X Title: $�•r'w car{a/o s Date: Zl'2S l92 FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return a71 copies to: San Joaquin County Public Health Services. Imrironmental health Permit/Services 1601 E. Hazelton Ave., P 0 Box 2009, Stockton, CA 95201 INFO EEE AMOUNT DUE AMOUNT REMITTED CASH CK 10 RECEIVED 9Y DATE PERMIT'NO. EM;3.s,t11Ev.r,pis) EN 1416