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�.. , APPLICATION ... S( # �f SAN Tn"W COUNTY PUBLIC HEALTH SERVICES ,4 .^ ENV ONMENTAL HEALTH DIVISION n �� # JOAQUIN, PHONE (209)468-3420 FAC # P O B % 2009 , STOC%TON, CA 95201 �� 9Z- 77 h11� PERMIT IRES 1 YEAR FROM DATE ISSUED L INV # C omplete in Triplicate) App cat on 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 gaI6 zo )z C�ily A, iim- f Size/Acreage Owner's Name C.4 Address i _ Phone - i r Contractor Address .r - ` "`" License No. Phone- -- TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION C Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i,;L INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing N Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I') Public 1-1 Other n'Delia Depth of Grout Seal Type of Grout I I Imijalmn _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type, of Pump N.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK. NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sower is available within 200 last.) Installation will serve: Residence_ Commercial _ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKC. TREATMENT PIT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. g Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 Sen Joaquin County Home owner or licensed agent's signature conifies 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 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 applicant m/kat call for all required inspections. Complete drawing on reverse side. Signed X___-,< Title: l 1 -2 r ✓I"-"i Date: — ?— FOR DEPARTMENT USE ONLY Application Accepted by %, �-"-" �-- Date -Z Area Pit or Grout Inapeotion by Data Final Inspection by c, AA ajlq�w Dau Oil- /1-[I Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIIV�ED�BY DATE PERMIT�{NjO. . EM 1}24 they.l r a er -7 �� "W < a- !N 1&A