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f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ApplicatSon In 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 Ban Joaquin County Ordinance No. 549 and 1and the Rules and Regulations of San 662 Joaquin County Public Health Services. $ Job Address City Lot Size/Acreage 3G0' x z93' Owner's Name C Add E r�lris ress CA Phone 146'$1-0 Contractor Add reS ress License No. L29794 Phone VPI0- 9�- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C] Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR C] Bon,K!4 OTHER Monitoring Well C7 DISTANCE TO NEAREST; SEPTIC TANK _�1//L SEWER LINES ISqtr DISPOSAL FLD.,„� PROP. LINE FOUNDATION 2A AGRICULTURE WELL N AA/ OTHER WELL R PITS/SUMPS NA INTENDED USE/vVA TYPE OF WELL%PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca Dia. -- Well Excavation__. ---: D Domestic/Private ❑ Gravel Pack C7 Tracy —;►--- Dia. of Well Casing fu i' Type of Casing__ A! !r l'1 Public (-I Other >�------ Specifications 1 Delta Depth of Grout Seal �-30 fiv + I Irrigation � Type of Grout AMA —.Approx. Depth I I Eastern Surface Seal Installed b i- Repair Work Done V0 Type of Pum by i--, . P H.P. ,._. Well Destruction ❑ Well Diameter Sealing Material & Depth State Work Dona Depth Filler Materl il-& Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ! DESTRUCTION I I (No septic system permitted if public sewer is u/A 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 feet: SEPTIC TANKWater table depth ❑ Type/Mfg Capacity— No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation �T. Property Line LEACHING LINEN/A ❑ No. & Length of lines FILTER BEDTotal length/size ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS 111A L) Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line . I hereby certify that I have prepared this application and that the work will be done in accord rules and regulations of the San Joaquin County ance with San Joaquin county ordinances, state laws, and 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." Contractors hiring or sub-contracting signature a- tion laws of California." certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall amploY Persons subject to workman's compens The applicantm ust fored inspections. Complete drawing on averse side.Cs�� pt�'�acLwc) F►4ixv) Signed X f �I i Title: C /• run a Date: FOR DEPARTMENT USE ONLY Application Ac Date Area Pit or Grout InDate q,4 L- Final Inspection by Date�•�j .�� Additional Comments.- Applicant omments:Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 t;ox 2 , Stka, CA 95201 FEE i INFO AMOUNT DUE AMOUNT REMITTED CK E IVSD 13Y //��,,,, CASH DATE PERMIT NO. . EN13241AfV.iiHst s� SYiv1� EH t4•� �� I V Gl Z cf CJS�7 �