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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENFAL HEALTH DIVISION 445 N SAN JOAQNIN, P�H,,,,O**NE (209)468-3420 �4 P 0 BOX 2009, STOfttW �Ui-PUBLIC HF 4'.rH SERVICES E VIPs-\, 'VTAL HE,4.t --- PERMIT EXPIRES 1 YEAR FRO ATA,JSSU (Comple in Triol :t'�� T p Application is hereby made 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. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address I (oQ0 U PQ Y k A t^" ►'/'f i4✓ City-re- r-77 Lot Size/Acreage 16 x I Owner's NameG e.-0 if v 42- t Sl, i Address 16 0 4) P(A rk-4 r" e`er Phone 7 9 Contractor f A- LJA('�4- CO ICI-Address 0 K 230 r7 G Y License No.B`3 3 Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p 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 A Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications N% i'1 Public f:1 Other 11 Delta Depth of Grout Seal Type of Grout 'N I I Ifrigatioo — Approx. Depth I I Eastern Surlace Seal Installed by -- Q Repair Work Done (3 Type of Pump H.P. State Work Done_ 0 Well Destruction © Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION f I DESTRUCTION I i 1No septic system permitted if public sewer is available within 200 feet.) Installation will servo: Residence Commercial_, Other Number of living units: - Number of bedrooms LA O Character of soil to a depth of 3 feet: L 0 A ^ Water table depth SEPTIC TANKType/Mfg 4" CC)r�C r2 � Capacity 12-O Q No. Compartments PKG. TREATMENT PLT. 0 if Method of Disposal Distance to nearest: Well�� Foundation 3 6' Property Line .S0 LEACHING LINE P-eNo. & Length of lines 2=0 Total length/size Z (�1 FILTER BED [.l Distance to nearest: Well -0D Foundation Sa' Property Line �•.�_ SEEPAGE PITS I I Depth 7 - Size Number SUMPS L11'4'�'Distance to nearest: Well r3 D Foundation Property Line DISPOSAL PONDS ❑ I 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 sub-contracting signature certifies the followi "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- tion laws of Ca' ornia ' The applica st' II for aqm c ' Complete drawing on reverse side. f Signal 'l Title: .t! >?,�d-OA Date: AOR DEPARTMENT USE ONLY [� Application Accepted by Date 7 A ueh /6 Pit or Grout Inspection by Date Final Inspection b Date 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, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO . EH 13-24lREV.riwei //e/•v6 1/ i6 �� Q�3 X13-0633 EH 14.2E