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ADPL I CAT I O SAN JOAQUIN COUNTY PUBLIC HZQ+rSIFi ENVIRONMENTAL HEAD TON 445 N SAN JOAQUIN, PHO L 4-v-j d P O BOX 2009, STOCgM 52b " A ' PERMIT EXPIRES I YEAR E / (Complete in Tr 6-r'aP4 /Wo S_ old S, sEnJp Application if hereby made.to1San Joaquin County for a perrai to construct and/or ins This application is made in compliance with San Joaquin County O7 ld ance No. 549 and 1862 and the Rules and Regu of San Joaquin County Public Health Services. .{ Job Address City • Lot Size/Acreage Owner's Name S11917 Ats g 0C.4, Address Phone Contractor [lrr4 Address License No. 1"ggPhone TYPE Of WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT t l DESTRUCTION Out of Service well C❑ 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing f7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I"1 Public Cl Other n Delta Depth of Grout Seal Type of Grout I 1 Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. __ — State Work Done Well Destruction Welt Diameter �l o_ ming Material & Depth Depth _ ` Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION t I (No 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lina ` LEACHING LINE ❑ No. & 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 Line 6 DISPOSAL PONDS 0 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 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 workmen's compensa- tion laws of Californ The applicant st all for requ' ed spections. Complet drawing on rev rse si 1/1 Signed Title: J Data: FOR DEPA MENT USE.,ONLY 0 1 Application Accepted byAArea Pit or Grout Inspection by Date Final Inspection by ate0r4 Additional Comments' g /f f `/J/ - Return all copies to: San Joaquin County Public Health SService, S Hap— Applicant Environmental Health Permit/Services L , 445 N San Joaquin, P O Box 2009, Stkn, CA 95201rsLoon t44 49a FEE AMOUNT DUE AMOUNT R I ED RECEIVED 9Y DATE INFO ' . EH 19-24 tREY.f 1 n til 1076jl+J " S J EH 14.20 ✓