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SAN vAQUIN COUNTY PUBLIC HEALTH r.dRVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, 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 in made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Cy .r" Ole Job Address /1�.,1 r/ETy � �L�. ! City � Lot Size/Acreage 3r3/fG;r<,V Owner's Name "yAEC�R��,,/ Phone Contractor J�'/�jrC/y(/ ;E SCAM Address 6C6� �i LEr�gU/0 License NoYPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 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 LIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ _ Specifications I"'. Public f-1 Other n Delta Depth of Grout Seal _ Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 4 Depth (� Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is \ available within 200 feet.) Installation will serve: Residence L Commercial _ Other Number of living units: _L Number of bedrooms Character of soil to a depth of 3 feet: _ p,/pP Water table depth SEPTIC TANK ❑ Type/Mfg OWN C,9s7 Capacity /A 00 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal �\ Distance to nearest Well j#04" Foundation �C Property Line r�� LEACHING LINE Rr No. & Length of lines Total length/sire FILTER BED ❑ Distance to nearest: Well i PO Foundation Alf r Property Line l SEEPAGE PITS Depth 't S Sire 346 U/A• Number 21 SUMPS LI Distance to nearest: Well / oil Foundation xd Property Line 00' 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 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant mu call for all required inspections. Complete drawing on reverse side. Signed % �[k Title: Date: e FOR DEPARTMENT USE ONLY 5- 24 Application Accepted by ` Date Areai or Grout Inspection by Date �3 Final Inspection by 1 Will it l v xZ 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 FEEINFO AMO NT DUE AMOUNT REMITTED CASH IVED BY D 7E PEMI7'NO. . EN I;3.24tflEV.t/nal r �a/ 9V3 EN 1614 '` /