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SAN QUIN COUNTY PUBLIC HEALTH VICES "tNVIRONI[ENTAL HEALTH DIVISI01r' 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED COPY (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 &Jvz�rJ�/ �Dy ©O 1`q�JiL', -p� City 44w;—, Lot Size/Acreage �D Job Address 'j Owner's Name , Address Phone C X71 3 Contractor ass icense No.a7 v 7 Phone TYPE OF WELL/PUMP: NEW WELI ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of easing_ Specifications \ I') Public ❑ Other fl Delta Depth of Grout Seal Type of Grout Irrigation _l�pprox. Depth 1 I Eastern SurlacetiSeul Installed by Repair Work Done ❑ Type o Pump H.P. State Work Done _ (� Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION fel REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Rosi nce Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: y �� Water table depth \\^ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1W\� PKG. TREATMENT PLT. ❑ 'I-d7-!-f Method of Disposal �(�V Distance to nearest: Well Foundation Property Line \ LEACHING LINE ❑ No. 8 Length of lines Total Iarigth/size �/� FILTER BED CI Distance to nearest: Well � Foundation •y � Property Line _,�14 SE GE PITS 11 Depth ize fi Number UMP LI Distance to nearest: Well Foundation_{_r .Property Line AV 9P V ISPOSAL PONDS O 1 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 comity that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." e applicant IyL MI r nspoct late drawing on rgve ids. Sag Si nod K i Title: Date: •. FOR DEPARTMENT USE ONLY w Application A cepted by-7--aDateSIL _ YC/ 2 Area 2 Pito nape taf fi� Zia DateC_� nal Inspection by��- / Data 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 LINFEFAMOUNT DUE AMOUNT REMITTED CRECEIVED BY 0 TE PERMIT'NO. . EH it2•(REy..in5) V/// O/ //// O/ ✓ . i V_ _— 1�+0� FH 1• de