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9� -is9G 00050 ?- SAN J QUIN COUNTY PUBLIC HEALTH S VICES TsNV I RONMENTAL HEALTH D I V I S I OIC- _ 445 N SAN JOAQUIN, PHONE (209)468-3421 P O BOX 2009, STOC%TON, CA 95201 b PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1)e5 0 (Complete in Triplicate) tic %Y�3 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 cmupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. STT L {"�n///1 ` ,Q� Job Address �-3 (J �7 /r / I/(/Q��" -12CLC 4 City Lot Size/Acreage Owner's Na/,,n/ 7 ,J/ieT(�/ ( Address T.5C+ �'t e Phone Contractor ;< -e r W !-.!L= Address e /�AW P License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 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 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing-. Specifications WPublic I1 other ❑ Delta Depth of Grout Seal Type of Grout — i I Irrigation _ Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done ;N Type of Pump 5 H.P. ;Z State Work Don 2 Sealing Material i Depth r Well Destruction Well Diameter 1— Depth __/.35 Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted it public sewer is \ available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: _ Number of bedrooms Character of and to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 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 agents 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 of 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 appb mus all for all require slec�ti+ons. Complete drawing on//eo/&e side. Signed X.�-- r -t�� Title: �{� Date: el FOR DEPARTMENT USE ONLY �j.. Application Accepted by Date D A{ea,d` Pit or ou nape' bn Dy Date Final Inapactio by /�1.3' Date + / Additi om"nbf: Applicant - Return all copies to: San Joaquin County Public Health Serv].ces Environmental Health Permit/Services 495 N San Joaquin Box 2009, Stkn, CA 95201 ( ` O 9�FEE MOUNT E AMOUNT REMITTED K H EIVED By DAT PERMIT NO. ;I 53 tPD/.,, wfi es'