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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P 0 BOX 2009, STOC%TON, CA 95201 PERMIT R IRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin Count fore q Y permit to construct and/or install the cork 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 ISL 4..7 ,S. S=" eAfeC_41! ,. RD City E-Sd44Q..1 Lot Size creag Owner's Name 12 S CdJ 7"0,4Z Address S S7""'/tom � G Z) Phone Jr.3F Contractor _ Z-0YD- lc/ Address A4AaL License fio.?/1T2-9(,�`Phone S S.?71 TYPE OF WELL/PUMP: NEW WELL CD WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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. n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing Cl Domestic/Private 0 Gravel Pack7 p Tracy Type of Casing_ Specifications Il Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout 13 Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H,P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.i Installation will serve: Residence✓Commercial— Other Number of living units: —,/— Number of bedrooms Z- Character of soil to a depth of 3 feet: -_ Ae�Q'ie Water table depth {� SEPTIC TANK ❑ Type/Mfg G^ Capacity &C No. Compartments 7— PKG. TREATMENT PLT. ❑ Method of Disposal {� Distance to nearest: Well 3�d r` Foundation S Property Line 6= V LEACHING LINE No. & Length of lines Total length/site 4� ` FILTER BED ❑ Distance to nearest: Well_. 14!P Foundation _ 7-0 ` _ Property Line /cftl SEEPAGE PITS VI Depth f Size 2_X 1.7 Number SUMPS K Distance to nearest: Well 3o erI Foundation 7.0 ' _ Property Line DISPOSAL PONDS ❑ T 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 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 call for all required insPections. Complete drawing on reverse side. Signed K Title: Date: 9 �PART�NTUSE ONLY Application Accepted by Date res Pit or Grout Inspection by Date Final Inspection by Date Additional Comments:. Applicant - ftetu.rn all copies to: San Joaquin County Public Health Services s Environmental Health permit/Services 445 N San Joaquin, bx 2009, Stkn, CA 95201 UF'O NT DUE AMOUNT REMITTED CKCEIVEp BY DATE PERMIT'NO. INCA EH 1}2t INEV. /wSl EH ti•2e 6