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.S SAN`xxsOAQUIN COUNTY PUBLIC HEALTH"IeERVICES /L`Frxr (F kill, ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOC%TON, CA 95201 \ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED -Z �` (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 Sen Joaquin County Public Health Services. �" /TV Job Address �� /�C�ny ? Z Lots Size/Ac reage�ji� XOwner's Nam {�{�(�!/}�-=moi Address �L`(_Nt/ 0X 130 CtiM Phoneo � ,/ _ Yet _ /�6:ontraclp��'�r1i�+i1 A re d>!'I License Not�(Zf PhoneU � 0`� TYPE OF WELL/PUMP. NEW WELL WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTUREWELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excava o Dia. of Well Casing ;K Domestic/Private CI Gravel Peck L1 Tracy Type of Casing Specifications — I'I Public 1-1Othern Delta Depth of Grout Seal d Type of Grou ES71w'��° C^^" I I Irrigation _ Approx. Depth I I Eastern Su a Soul Installed by `l Repair Work Done LJ Type of Pump H.P. St Work Dost Well Destruction ❑ Well Diame r Sealing Materiel i Depth Depth Filler Materiel Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public saws( is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of coif to•depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg C ityT_ No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well otindtition Property Line \v_� LEACHING LINE Cl No. b Length of li Total length/size FILTER BED ❑ Distance to rJe rest: Well Foundation Properly Line SEEPAGE PITS It Depth — Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby candy 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 canities 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 workmen's compensa- tion laws of California." ...,,,/// The applicant �Z11 call for all required ins ions.tons. C/oOR e{(/g7drawing on reverse side. �/� / /� Signed X/ /�iL'✓c�_ ✓t �'A Title: (� �42� / i r CA ( . (U \ / Data: FOR DEPARTMENT USE ONLY .�1L igApplication Accepted by � 111 Date �� Area fliPit Gr Inspection b r' Date / ( c Final Inspection by P Data J Y Additional Comments: Jr- ( / J7w�oA. Applicant - Return all pies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFtOI AMOUNT DUE AMOUNT REMITTED CAKSH RECEIVED BY DATE PERM17 NO. EM 4.28IREV.rriier N , / ! r9p �7 Z. p ' �/ / 2_- / ISL 3a 47 9293$ y