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SAN 1QUIN COUNTY PUBLIC HEALTH f '.VICES �-ENVIRONMENTAL HEALTH DIVISIOfr' 445 N SAN JOAQUIN•, PHONE (209)468-3420 P 0 BOX 2000, 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 Publlic[Health TServices. ./1�, 14.4o / / XVrH )pn ef0 Cit 4 Lot Size/Acreage Job Address^{J `v 93 Owner's NameHn Address (.1 W{G�//Urcj/// Phone " (� Contractor e.14� u�� ddres� �� ok ( 1 Tense No.((Q1 73 Phone J TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L1 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 Die. of Well Excavation 011: of Well Casing LI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public 1.1 Other 71 Delta Depth of Grout Seal Type of Grout I I Irrigation /_Approx, Depths .1 1 Eastern Su ce Soul Installed by Repair Work Done W Type of Pump p H.P. State Work Done0,0 Well Destruction ❑ Well Diameter Sealing 1 teriel 6 Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is _ A available within 200 fast.l Installation will serve: Residence_ Cdtnmercial_ Other A l l Number of living units: _ Number of a dreoms _ Character of soil to a depth of 3 feet: _i -Masi table depth SEPTIC TANK ❑ Type/Mfg Capacit No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest:' , We Foun "ion�_ Property Lina LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Si Number SUMPS LI Distance to nearest: ell oundation Property Line DISPOSAL PONDS ❑ 1 hereby cartify that I have prepared this applicati and that the work will be one in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Coun Home owner or lis rid signature certifies the following: "I certify that in a performance of the work for which this permit is issued, I shall not employ any pe n in such near as to become subject to workman's compansatin laws of California." Contractor's hiring or sub-contracting signature certifies the Ik wing: "I ce ify that in the pe rmancs work for which this per 't is issued, I shall employ persons subject to workman's compensa- tion lawn Californ . The ap Icant m for 11 req d plate rawing on rev si //� / > ' Signed Title: �� , 0.4eg4 : Vr_ 16--2 R DEPARTMENT USE ONLY Application Accepted by liz Date Area Pit or Grout Inspection by Date Final Inspection by ^' Date _Z Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services _fv Environmental Health Permit/Services _['p 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEFO AMCASH OUNT DUE AMOUNT REMITTED RECEI D BY DATE PERMIT NO. I T4IREV.fill a1VM