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' 4 *APPLICATION 6, i3 4 � -5 Im 7 SAN JOA QUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 �?` P O BOX 2009, STOCKT ON, CA 95201 _ a , 'PERMIT R IRES 1 YEAR FROM DATE ISSU (Complete in Triplicate) Application is hereby made to Saan, Joaquin county for a permit to construct and/or install the vork er desc bed. This his application is made in Compliance] vith San Joaquin County Ordinance No. 51+9 and 1$62 and the Rules and Regulat ons of San Joaquin County Public Health Services. Job Address IUAZ� City—7'�MC V Lot Size/Acreage Owner's Name _ yf � 1 Address C i W. ` . ! r rlJl�Lr�phons �(�s �/ c Contractor � Address f License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR M 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ca Domestic/Private ❑ Gravel Pack P Tracy Type of Casing, Specifications I') Public C1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx.,Depth t I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. ___ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material aE Depth f� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION 1 I (No septic system permitted if public sewer is `V^ available within 200 feet.) Installation will serve: Residence T 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 tol.nearest- Well Foundation Property Line LEACHING LINE No. & Leng t __. e� Total length/size 1 I FILTER BED ❑ Distance to nearest: of lines nearest: Well�JFoundation c_A60 Property Line f SEEPAGE PITS 11 Depth � -Size Number i SUMPS 0 Distance to nearest: Well Foundation Property Line ; DISPOSAL PONDS ❑ i 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 sub-contracting 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 workman's compensa- tion laws of California." The applican st call for all required i ".ctions. Complete drawing on reverse side. ned , g Title: Si Date: }a, FOR DEPARTMENT USE ONLY Application Accepted by �Q•�� Date Pit or Grout Inspection by Area Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services LI Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 FEE EAMOUNT DUE AMOUNT REMITTED CSN RECEIVED BY GATE PERMIT'NO. EH 14.211RSV,tin5t VV ! � •6D I�VQ /�/�/ �� `.,� �� / EH 14.2a