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APPLICATION �I —� 1 ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 1^ ENVIRONMENTAL HEALTH DIVISION �31�q 445 N SAN JOAQUIN, PHONE (209)468-3420 1 P O BOX 2009, STOC%TON, CA 95201 ILI PERMIT EXPIRES 1 YEAR FROM DATE ISSUID � (Complete in Triplicate) vv c1 � I y Application is hereby made,to San Joaquin County for a permit to construct and/or install the work her Sn described. This application is made in compliance with San Joaquin sC_Qun_ty�Oytnance No. 549 and 1862 and the Rules an Regulations of San Joaquin County 1Publlc,Health �ervices. ©f (�_,R'Gyy(L{�41 {/GF rJ! A e� r" �t'r"� � City ��pz Lot Size/Acreage _ Jab Address y� , y� `1V V,z Address •v[ v Phone .� (f J,J� .rte Owner's Name /�� / "(��PtaS'�'t IOD -r. 72 ~ Contractor 7 "a r e Address I fa License No. G•.Phone ice Well 0 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl D TRUCTION ❑ Out of Seoring Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 'OTHE- {^ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES AL FLD. PROP, LI FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS Dia. of Well Casing /1 fl Industrial Open Bottom ❑ Manteca Dia. of Well Excavation [:I Domestic/Private ❑ Gravel Pack ❑ Tracy Type o1 Casing,-- I'] asing. _ .-- Specifications— `�'�� e 1']��sss��Pu---blic I-1 Other fl Delta Depth of Grout Seal Type of Grout Dation —Approx. Depth I I Eastern Surface Seal Installed by /R*e'peu Work Done ❑ Type of Pump H.P. Depth State3 W rk Done _ ' Well Destruction C] Well Material 6 Well Diameter Filler Material i Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo availabpeiw shin system Peermined it public sewer is Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth n SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length o1 lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I 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 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, I shall employ persons subject to workman's compensa- tion Iowa of Calif me." The applicant z_aU-ra ued tions. Complete drawing on r/sv,,,,��yyy#s/e std rte.Zi Signed li / Title: i�-y FOR DEPARTMENT USE ONLY � Ap Iication Accepted by *00 Date Area Pit Gr t Inspection by Data I Inspection by �LDate�—Z 9 AdditienaF fiemmenfc"- 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 FEE AMOUNT DUE AMOUNT REMITTEDCK 11 RECEIVED BY DATE PERMITNO. INFO CAS" ,.iaov „aa. IA,G 5F,?�- ycd/ I a-ova/