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APPLICA"'LJN FOR PERMIT SAN�AQUIN COUNTY PUBLIC HEALTH . RRVICES 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address -T`iI C,I-Xii,�t Wt tet-- City SOU Lot Size/Acreage Owner's Name ARCO P,-a MULES l-0 - Address RQ ROK SOU Phone Contractor SCa�f �xP�D��T�rt Address Mo 14MiLJG1K1driVe License No. E'� � Phone /6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ ell PUMP INSTALLATION O SYSTEM REPAIR ED �O�THHER ❑ monitoring _cT , aLINE��A DISTANCE TO NEAREST; SEPTIC TANK>5-0L50 DISPOSAL FLD.� PROP.SEWER LINES _ FOUNDATION 420 _ AGRICULTURE WELL 7S� OTHER WELL>— PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS yet L) industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private AGravel Pack ❑ Tracy Type of Casing Sl hLin ?VC Specifications I'I Public 171 Other fl Delta Depth of Grout Seal Type of Groutlb'•7 � ll 11 s•v .L�//A"ri t I I litigation _Approx. Depth pLEaslern Surface Seal Instilled Dyy` ^ Repair Work Done L3Type of Pump H.P. Stale Work Done _ Well Destruction ❑ Well Diameter Sealing Materisl L Depth Depth Tiller Material a Depth t� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system 200 rented if public sewer is tom\ Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of will 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 Lim LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lina +--- SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to interest: Well Foundation Property Lina 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 Ina 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 canities the following: "I comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workmen's compensa- tion lawn of California." The applicant at call or 11 r fired inspections. Complete drawing on reverse side. /',., /), Signed X- Title:Title: 1/'o-.�-.,'�_(.�Y7,6iDate: 1 g Of "�l FOR DEPARTMENT USE ONLY 7 Application Accepted by l, _ Date `Area q Pit or Grout Inspection by Date inal Inspection by Den Additional Comments; Applicant - Return all copies to: San Joaquin County Public Health Services 7�� Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVE BY GATE PERMIT NO INFO . EH 13-241ftEV.i/n5, 11([�� EH 14"2a