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S SAN JOAQUIN COUNTY PbBLIC HEALTH SERVICES y ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 f 5-yldy S ©s y/� P O BOX 2009, STOC%TON, CA 95201 SrtTL PERMIT EXPIRES 1 YFAR FROM DATE ISSUED (Complete in Triplicate) ITN / 1 t Application is hereby made.to Sass Joaquin County for a permit to construct snd/or install the work herein described. This application is made in compliance with San Joaquin County Ordimlic No. 569 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job AddressAlf�Vo - - Lot Size/Acreage Owner's NamAddress 0. ePhonec// �/�' Y �i'tL Addressa - License No. `. �JG Phone( Tom'" Conuactors Service Well TYPE OF WELL/PUMP: NEW WELL [3WELL REPLACEMENT Cl DESTRUCTION L1 out Monl Loring Well ❑ PUMP INSTALLATION Ar SYSTEM REPAIR ❑ OTHER ❑ ❑ 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 O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel PTracy Type of Casing_. Specifications eck [I I') Public 1-1 Other Ll Delta Depth o1 Grout Seal _ Type o1 Grout Irrigation _Approx. Depth ,� Eastern Surface Saul Installed by \ f` Repair Work Done & Type of Pump . . 7 State Work Dona HP ' Well Destruction ❑ Well Diameter Sealing Katerial & Depth Q Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feetA Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to s depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.Cl Method of Disposal Distance to nearest: Well Foundation Property Cine `N LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 canities 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 meaner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I cartity 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 Lsl' 1 - Tha nt must for all required Co/o/n/s.'Complete tlrawin/�°/-averse sido r> Signed X �l-li-�---- Titly r�f Date: '�,I,t�,',t//I._,, FOR DEPARTMENT USE ONLY �] Application Accepted by Sam.,('/✓lt�t,v+' Dat i' f a -9 3 Area v' � 2— Pit or Grout Inspection by Data Final Inspection by—/ ��L Date 3 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services �jx 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 /�/`)�'{7/, y/f INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PER MIT'NO. E.i124 IRS,tI,,., �, ER Ir a1