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SAN *UIN COUNTY PUBLIC HEALTH #ICES 'r . ENVIRONMENTAL HEALTH DIVISION „t 445 N SAN JOAQUIN, PHONE (209)468-3420 ¢ T P O BOX 2009, STOC%TON, CA 95201 �tC �/ D J PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 0 3 1.093 (Complete in Triplicate) SAN JCAQUINCCJNTY PUBLIC HCALT cc{, I Application is hereby made,to Sm Joaquin County for a permit to construct and/or SnstallEtfldpRUI@?�nAY,t�ed•.ESTh1s application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules anda k'a'.1% jem Joaquin County Public Health1 Services. Job Address �l �i�i^ J �/y/t�-'iCJ �K City ,— �L. Lot Size/Acreage ?f-e`X/L/r �Q-f1 f1748dress 1% %,•v ”-`'-^- /-1• 9//,(,, Phone Owner's Name e'✓�u'•�=�-�-- Grc zodaT ��,4/-3y-W3 Pnone�Y/6 - Conuactor ^ Address 41 .S�-.CfC/-m1/4�%s� Tci/ License No. TV PE OF WELL/PUMP NEW WELL WELL REPLACEMENT DESTRUCTION ❑ Out of Service Nell ❑ Monitoring Well C]PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing z/n j7VC Soecilicatlons f.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ y Type of Grout &to-) I'I Public Other fl Delta Depth of Grout Seal Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Z�'" r � Repair Work Done ❑ Type of Pump H.P. State Work Done _ u y Sealing Material & Depth /6/ Well Destruction ❑ Well Diameter `` knf l L -� Depth ` Q• 14— Filler Material & Depth �C✓)G/ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INO availabellw shin system permit it public sower is IT J. Installation will serve: Residence _ Commercial_ Other Number of living units: _ Number of bedrooms Character of and to a depth of 3 feet: Water a depth SEPTIC TANK ❑ Type/Mfg Capacity No. Commpartments Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line 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 DISPOSAL PONDS ❑ 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 ' "I certify that in the performance n the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following:men's compensation laws of California." Coctractor's hiring or subcontracting signature employ any person in such manner as to become subject to work 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. CompletI drawing onn�reverse side. 1 Signed Xl1 a n , �r �l` t i i f✓y cxrlCr r r r'I Title: Lel '1rT7` iJt�z. C Date: g T FQR nDEPARTMENT USE ONLY (j c Date � Area �— Application Accepted by �'� dJ�,�, i^ Pit or Grout Inspection by ILL1wU ate nj W ( � Final Inspection by Y A uC T` Oata/—/L Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services .1 L VCJ 445 N San Joaquin, P O Box 2009, Stk., CA 95201 FEE CK RECEIVED BY DATE PERMIT NO. INfO AMOUNT DUE AMOUNT REMITTED CASH EH 13-24(REV.11M51 f\�lJ`� V t` 0" EH 1410