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-APPLIC',TTON • 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. nn r�I 06 _ Q Job Address yV y l -`�v �'"" City Lot Size/Acreage V �efGnse l�i5fi� �cJPi17Gc " shy/eP4 160447 01 95.330 209 p Owner's Name Addres l%$2—ZbBG _ Phone (�Yeq�}�rllli�g8 /eshn � �a Howey e /y��7`ioca C oC G C fir, Contractor 0(1 / Address _ �'9 / License NoC/�� o✓��/P honeJ/03�35pt�// TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Tl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ q011 dorIn10THER)q 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 SPECIFICA IONS ❑ industrial ❑ Open Bottom C1Manteca Dia. of Well Excavation _ Dia. of Well Caning 11 Domestic/Private ❑ Gravel Pack >TTracy Type of Casing_ qq WAG Specifications � - Il Public 17 Other n Delta Depth of Grout Seal J Z[u Type of-Grout Irrigation _Approx. Depth I I Eastern Surface Seal Installed by_�qT �/��/JI t Repair Work Done ❑ Type of Pump H.P. St to WorkQ one Well Destruction ❑ Well Diameter Sealing Material i Depth U�419 Depth Filler Material i Depth /�Q( r2"fI7274, G�/ilG/iw�i3r"O�^7. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 Line LEACHING LINE ❑ No. i 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 O 1 hereby cenify, 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 cenifies 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 persona subject to workman's compensa- tion laws of California." The applic t mus )call for all required inspections. Complete drawing o reverSiide. / Signed X Title: � se rol'ec/1 ts: rly �vV A'd7?� Oa FOR DEPARTMENT USE ONLY Application Accepted by Date `S ( C v Area 7 Pit or Grout Inspection by ry(' ate �/' Final Inspection by Dau Additional Comments: 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 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RAE.C,EI,VtED BY DATE PERMIT NO. . EM Ia-N IREV. ER u.as