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APPLICATION. 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) Application is 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 San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Ki ob Address = Gc [s� City ] Lot Size/Acreage f�1 / �wner's Name s Address � t __ __ Phone j7 7 ,c /� r�C� �., I� Contractor [ yr.�_ /� _ - Address - 1 ?3 1"Ze&D r License No, p 6 Phone b- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEM T Cl DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM AIR L) OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRkCULTUAE W LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM REA C STRUCTJON-SAEGIFICATIONS _,-__ �--- L7 Industrial ❑ Open Bottom ❑ Manteca �a- of Well Excavation Dia. of Well Casing Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_- Specifications ,.. i'1 Public 1-1 Other 11 Delta th of Grout Seal type of Grout—_- I I Irrioation _.Approx. Depth I I Eastern Surla Saul Installed by ; Repair Work Done L7 Type of Pump H.P. State Work Done y Well Destruction ❑ Well Diameter Sea.liag Material i h Depth Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/A bDITION I I DESTRUCTION I I (No sap!iic.system permitted if public'sewer is available.tivithin 200 feet.) Installation will serve: Residence�.. Commercial_ Other i..� Number of living units: .. _ Number of bedrooms --2— 1 Lr({ Character of soil to a depth of 3 feet: __. t I Water table depth SEPTIC TANK. 0'Type/Mfg ._��i�a - Pl- Capacity_ No. Compartments PKG. TREATMENT PLT.❑ r�/ � Method of Disposal J , Distance to nearest: Well [�' Foundation � Property Line 23 c,0 ` LEACHING LINE P--Iqo. & Length of lines __. j Total length/size FILTER BED [:l Distance to nearest: Well _ Fo7sric�ationQ Property Line J S� 1 SEEPAGE PITS I I Depth Size Number - SUMPS Ll Distance to nearest: Well `Foundation ) �roperty Line s�C D SPOSAL PONDS ❑ I hereby certify that I have prepared.this application and that the wofk will be done in accordance with an Joiquin c6unty�6rdinances, sole laws, and rules and regulations of the San Joaquin County" I " Horne owner or licensed ' a ents signature certifies the followin 1 t !' 9 g g: "I certity that in the performance of the wfitk 0,which this permit is issu�d, I shall not employ any person in such manner as to become subject to workman compensation laws of California."Co�iiactor'f hiring ry'�tib-contract signature certifies the following; "I certify that in the performance of the work for which this permit is issued, I shall emp .y-,perMn".ubject to workman s compensa- tion laws of Calif nia." The applicant t cal for all r �uired' ction . Complete drawig o erre side. wV _` Signed X Title: _1__" Dater / ''422— A 422— A DEPARTMEN USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date Z Z Additional Comments: " 6 Applicant - Return all copies to: San Joaquin County Public Health Services - Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT �REMITTED CK ASH/ RECEIVED BYEDATE �PjERMITIN�O. . EH 13-M{ttEV.I/x 5) -Q�1 /(,{! � 6V7/ " rEH 74.20 V ( !� l r 1