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o`t `76 Y 61 3 K F-49r, APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � L) ENVIRONMENTAL HEALTH DIVISION 5 e L A14/1 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOC%TON, CA 95201 z�� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) e �k Application is hereby made to Sm Joaquin County fore 1 i` kJ4 application is made in coarplimce vith San Joaquin countyrordinance nNofu549aando1862 and th lee and Aegullll�atlonedof San r Install t 9 Joaquin County,Public Health ServCiS�!le. Job Address _ dS77S —S 7a4"5D}'� P—a 5+S ��/� City T Lot 93 ze/Acreage A p 9t19Nlrc f 1 TTS Los 9.vyal�,S, Owner's Name ✓;rA /�Pla�jf'wp- a"o'Address r-/0 4-A. no "SA06(t10 f08Zy-?"'4 / none 9 b j 1 066 1 Ll✓aeatokf' Contractor Pyl lU fey /' Address 19C IJAIG4E Co un} License No. 93,2 Phone la 94 TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPLACEMENT FDESTRUCTION ❑ Out of Service Well L1PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON TR TION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Die. o ell Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Ty of sing_ Specifications 1'I Public 1-1 Other fl Delta p of out Seal Type of Grout I i Irrigation _Approx. Depth I I Eastern Surface Seel nstalled by Repair Work Done LJ Type of Pump H.P. State Work Done_ J Well Destruction ❑ Well Diameter ing Material i Depth Depth filler Materiel i Depth TYPE OF SEPTIC WORK: NEW INSTALLATIOJAI R AIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is A]� available within 200 feet.) Installation will serve: Residence— Commercial— Other y,.0 t 1p, Number of living units: _ Number of bedrooms O "�'� Character of wit to s depth of 3 feet: Water table depth I' SEPTIC TANK O Type/Mfg Capacity No. Compartments 22 17 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line O SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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, 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 following: "I 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 applicant must 5all for all required inspections. Complete drawing on reverse side. 7 Signed X *w Title: .1'��a Date: Application Accepted by C&AAv�i \{�Omz ONLY 7 [, �p �`i� JJ .�i^.'n1�� Area '�Z -f �'F-'�� Pit or Grout Inspection by Date Final Inspection by r v�"�t• Data�L Addnfonsl Comments: Applicant - Return all opies to: San Joaquin County Pug Sc Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. CK 11 • EM 17Q41REV.i/x51 N / ,o / EM 1414 _