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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 to P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I �7 XJob Address ��1 /E/. z, ;;�J City �G Ld Lot Size/Acreage xOwner's Name �� .Z27izi8- Address 77// 2aWZ1-/a/0 6�7l Phone -S.226 contractor Address Sgn G2 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well PUMP INSTALLATION ❑ SYSTEM REPAIR LlOTHER ❑ monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G'r S ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public I:1 Other fl Delta Depth of Grout Seal Type of Grout - I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L] Type of Pump H.P. __ State Work Done _ Well Destruction ❑ Well Diameter Sealing material i Depth Depth Filler material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted it public "wet 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 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina 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, an� 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 $hall nott7 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 following: "I certify that in t r nce of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of Calfforn The applicant t It to drawing on reverse side. U Signed 777 Title: o- G'uJnc'�'— Date: DEPARTMENT USE ONLY Application Accepted by Date Area a 7- Pit Pit or Grout Inspection by Date Final Inspection by Date /T Additional Comments: t Applicant - Return all copies t : San Joaquin County Public Health Services Environmental Health Permit/Services s(�Do ADO � (� 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO FEE AMOUNT DUE AMOUN/TREEEMITTED CK / RECEIVED BY //D�, TE (/PPEE,R/M�ITNO. . ENIYr m CJ24IaEV.1/MmlW c -pO DY- EH to