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`. APPLICATION SAN JOAQUIN COUNTY PUBLIC HEAL rH58U.LUhZjq ENVIRONMENTAL HEALTH DIV S # ql0 445 N SAN JOAQUIN, PHONE (20 - -'34ZU' P O BOX 2009, STOC%TON, CA PgCX)# PERMIT EXPIRES 1 YEAR FROM D TE 'IS UID G710 (Complete in Triplica,110 1. 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 Services. Job Address /Y C6!!7rr/ City 5'f Lot Size/Acreage7�11( Owner's Noma DA Lay r�Address--SaN1C Phone . —,=til Or ConBactor --f�{" �Y7/Y� Addressnal W-i"LI-Aense Nd:;�13 �Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavati Dia. of Well Casing • Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications I"I Public 1.1 Other fT Delta Depth or Grout ft 81) _ Type of Grout p I I Irrigation _Approx. Depth I I Eastern Surface Seel 1pp t p.11 Repair Work Done L3Type of Pump H.P. T J�N�0 iA'AIyC(�fJ rte_ \ Well Destruction ❑ Well Diameter Sealing Hater) f� �,f E• Depth Filler Material i Dep 'KE l VIC.F TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I 1 INo septic IM I m permitted it public cower is available within 200 feet.) Installation will verve: Residence '41t, Commercial _ Other Number of living units: _-t-- Number of bedrooms 3 s Character of soil to a depth of 3 feet: !_'1�3.y, — aegAEV H1W Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lina n, LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line �I t� SEEPAGE PITS Depth Ois;- Size �4umber SUMPS LI Distance to nearest: Well/� f^ Foundation S.E If- Property Line b`�t7 •�— m 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 Son Joaquin County Home owner or licensed agent's signature cenifies 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 persons subject to workman's compensa tion laws of California." The applicant must call for all requi �,n,,ction s. Cc plate drawing o(/��L.zz��wwJq�)rile sidle, SignedTitle: y�z� Date FOR DEPARTMENT USE ONLY Application Accepted by Date = t L Area —Z 2-- fy . or Grout Inspection by Date s �3� �/ Final Inspection by T6 /;!iPr"Gr-�9 Data S Jr 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 95201 FEE INFO AMOUNT DUD�E AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. • EN 13-24 tAEV.Ir4s� I .�!1✓ - �y/� {/ICY 1-9 EN 14.2e / ly / / j J