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SCANNED JOAQUIN COUNTY APPLICATION HEALTH SEgilCES---_ ENVIRONMENTAL HEALTH DIVISIO �$ 445 N SAN JOAQUIN, PHONE (2O9)468-342iI—____---- -_— P O BOX 2009, STOC%TON, CA� 4" PERMIT EXPIRES 1 YEAR FROM DA �/y (Complete in Triplicate) 3�� Application is hereby blade to San Joaquin County for a permit to construct and/or install the vork herein described. This application Is Pude In Hempliancealth vithServices. San Joaquin County Ordinance No. 549. 549 e_ N ., les and Regulations of San Joaquin CountyPublicNealth 9ervla�ee. �// / /p'f Job Address S � tom/ n City /� C�� '�--Lot Size/A eage Owner's Name's` ICA rhes �/OT�4 q 1!'K/ c� �PRa-ne Contractor1..1. n_�A(L. Addres��/� �� / ,/r�idL License No.��,2 Phoneiz� TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Sell ❑PUMP INSTALLATION ❑ SYSTEM REPAIR`,£� OTHER ❑ MonitoriWell LJ 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 Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing II Domestic/Private L) Gravel Pack ❑ Tracy Type of Casing_ Specifications (1'.II Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout ,.1lrngalion _.Approx. DI L 1,1 Eastern Surface Soul Installed by \ Repair Work Done >9Type of Pump c H.P. J�'2 C7 Stats Work Dons Wall Destruction ❑ Well Diameter Sealing Material a Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer 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 1 l tl SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments l PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE Ll No. 6 Length of lines Total length/size FILTER BED ❑ Distance to merest Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ \ I hereby csnify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, end /1t rules and regulations of the San Joaquin County Ilv Home owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall riot employ any person in such mainnar as to become wbject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 compone tion laws of California." The applic test call r all required inspections. Complete drawing on r !side. 1 - Signed Title: Date: Q •`/ FOR DEPARTMENT USE ONLY Application Accepted by ('{ lav✓ Dat Pit or Grout Inspection by Date Final Inspection E D Additional Comments: 77 Applicant - getGreall coDleb t C tearyb1lcfHealt�3erviCes /�� Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FSE AMO VNT DVE AMOUNT REMITTED CA H RECEIVED BY DATE -•►[IIMff . EH 1124 REV, I