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*ftw� APPLICATION SAN JOAQUIN COUNTY PUBLIC HEAL H Srut#I D ENVIRONMENTAL HEALTH DIV�SIQX 20 445 N SAN JOAQUIN, PHONE (209 4 P O BOX 2009, STOC%TON, CA` R PERMIT EXPIRES 1 YEAR FROM DA E S ED g (Complete in Triplicat )ii�d �O Application is hereby made to Sen Joaquin count for S applic9 y permit to construct and/or install the Rworkules herein described. This Joaquin County made in compliance withServices. San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San ` Joaquin County Public�H/ea`llth 9ervlcee. - Job Address Tj�, / C/�� S _ City Lot Lot Size/Acreage Owner's Name ala./�Yl �� Address �� (el J / I � Phone Contractoll / �- ddress ��7JA ense No. Pnone _ TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT D 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 r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T; n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing \vf C l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications asr CI Public fl Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrivalion _Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done LJ Type of Pump H.P. ___ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material L Depth r Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ESTRUCTION I I INo septic system permitted it public sewer is available within 200 last.) y r Installation will serve: Residence iL—Commercial Other -11 Number of living units: Number of b,Qrcorns �� c Character of sell to a depth of 3 feet: Water table depth V SEPTIC TANK ❑ Typa/Mfg Capacity No. Compartments r PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE M--Iq-o, 6 Length of lines �H T�1.1 length/size -� FILTER BED ❑ Distance to nearest: Weil _! Foundation !� Property Line ,r, SEEPAGE PITS N.—O"epth 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 Sen 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued. I shall employ parsons subject to workman's compensa- tion Is f California." ..r The eDPlica t r 1 cal for re fired ape omplete drawing on mea side. sig - Tide: �-�` f, Date: l/'� R DE�TMENT USE ONLY Application Accepted by `� .� Date _ Area Pit or Grout Inspection by Data Final Inspection by rc%c-r. Date 3 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services S,x Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT NO. �. EN 1t}211afV,1/x!1 EN 4.211