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APPLICATION SAN eedAQUIN COUNTY PUBLIC HEALTHsxa9RVICES 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 (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 ervlces. ��.rr Job Address 1---�+� City -Lt Size/Acreage 9�13� Owner's Name M L Address�✓F.d �� Phone Contract Address -V, License No.;IFS Pho TYPE OF WELLIPUMP:71 NEW WELL Cl WELL REPLACEMENT n 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 El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Die. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ N Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth V TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION INo septic system permitted if public sewer is available within 200 feelA Installation will serve: Residence Commercial_ Other Number of living units: ._ Number of bedrooms_? Character of soil to a depth of 3 feet: C LIAR/ Water table depth SEPTIC TANKN� *0 Type/Mfg ?�L. Capacity No. Compartments i PKG. TREATMENT PLT. ❑ e Method of Disposal Distance to nearest: Well Foundation I_ Property Line�r LEACHING LINE AWC170 No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 7 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lira 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." Contractors 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 or California." The applicant s for all require ins ions.,Comp a drawing on reverse side. Signed r Title:� /� Date: 4 RTMENT USE ONLY Application Accepted by - fQ1An •`r` �A►eA Date l L Area Z a PN or Grout Inspection by Date /) Final Inspection by LJw1i Date 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, Stirs, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE 6PERMIT*NOO. . EH 1124(REV.,rm 51C t:7 � 04Ulm EH E.2m