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l) ./ APPLICA, ION FOR PFFtplr ytG � A�IN COUNT PUBLIC HE ABHVTr=__ FHIVIRONMENTAL HEALTH D N SAN JOAQUIN, PHONE (2 �Wav l �Q O S �' P O BOX 2009, STOCSTON, fAe PERMIT EXPIRES I YEAR FR (Complete in Triplicat Application is hereby made'to San Joaquin County for a permit to construct and/or install the work here ®red. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rulegu Joaquin County Public Health Se�r-vvi�ces/.►/� pry Job Address _ 1 s7[ l �r 1 r„1nz�sc 1 City Lot Size/Acreage Owner's Name �,� � L��I'�,I� r� Address �• f7 .. _ Phone Contras for ,4ddress N•WL4 -5; License No Phone TYPE OF WELL/PUMP: NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' 14onitoring Well O DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD,— ,(.INE^� FOUNDATION AGRICULTURE WELL OTHER WELL d INTENDED USE TYPE OF-WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' ¢6 . 1 C1 Industrial b Open Bottom ❑ Manteca Dia. of Well Excavation_ _ fl E Oia202NIqf7 Ing C1 Domestic/Private ❑ Gravel Pack ❑ Tracy r Type of Casing_ e V 1'1 Public f-1 Other n Delta Depth of Grout Seat C 1_`yF1Wt_T`,,F; ;vii I I lrrigation -.Approx, Depth I I Eastern Surface Sea$ Installed byI A Repair Work Done ❑ Type of Pump H,P. State Work Done Well Destruction ❑ Well Diameter Sealing ltfaterial i Depth dt Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 leet.l Installation will serve: ' Residence� Commercial— Other 4 Number of living units. —I— Number of bedrooms r_ +� r v� Character of soil to a depth of 3.feet: Water table depth SEPTIC TANK-4X1-'S7_0 Type/Mfg Capacity No. Compartments t PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:. Well Foundation Property Line F4.1 LEACHING LINE No. E Length of lines Total length/size P FILTER BED ❑ Distance to nearest: , Well Foundation ' Property Line SEEPAGE PITS X •Depth �Sire .. �11 r2w ^ Number Z- SUMPS Ll Distance to nearest: Well Foundation Property line DISPOSAL PONDS ❑ I hereby certify that t 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 foilowing: "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: "l 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 of California." I The applicant must call for all required inspec ns. Complete rawing on side. S 1 ! Sign Title: Date: f FOR DEPART]M�EpNT USE ONLY Application Accepted by ___ / Date Z-- �'�' Area Z_ Z Pit or Grout Inspection by 'Date Final Inspection by L 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, Stkn, CA 85201 ( r I t FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO T D 6'} . EH113.74 IAEV.it it sl fH S4� g� -!