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L. SAN JOIN COUNTY PUBLIC HEALTH SERPSCES ENVIRONMENTAL HEALTH DIVISION L 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009 , STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) LApplication Is hereby made to San Joaquin County for a permit to construct and/or install the work herein described- This application in made in compliance with Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Is. U City atC Lot Sl ze/Ar reeae i L Owner's Name (L_TZ4)�,i ,/,,L/l' - Address phone /�- R '>6 '/ Y Contraclor—vYf L &]2 LC-�: Address I r i 6 , ZaZ�/t �icense Nom/i Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LT DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR ❑ OTHER 0 Mo,-..itoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS -_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industnaf ❑ Opan Bottom ❑ Manteca Dia- pl Well Excavation Dia. of Well Casing J Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specilicanons I-1 Public Ll Other fl Delta Depth of Grout Seal Type of Grout I knuanon _Approx. Depth I I Eastern Surface Seal Installed by Repan Work Done ❑ Type of Pump H.P. State Work Dona WaC Destruction ❑ Well Diameter Sealing Material L Depth Depth Filler Material L Depth (p TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/A001 TION DESTRUCTION I I (No septic system parmwnod it pu Dlic saws. is m available within 200 feet.) G Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms _ iii�� Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg - Capacity No. Compartments L PKG.TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LLEACHING LINE No. 8 Length of lines �� Total ength/size !e FT FILTER BED LI Distance to interest: Welt Foundation Propeny Line y LSEEPAGE PITS �1{I Depth h2 �- Size ��'��10 Y /0 _ Number Z SUMPS (< Distance to nearest: Well L56�w�1—T Foundation �6 F7" 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 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 or 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 applicant must call for all ra lied insp ttions. Complete drawing on ravens sills. Signed Title: Date: FOR DEPARTMENT USE ONLY 6- Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Onte Z Z. Va Additional Comments: Applicant - Return all copies to: San Joaquin County-Public Health Services Environmental Health Permit/Services - 445 N San Joaqqin, O Box 2009, Stkn, CA 95201 FEE NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO, 42-24tto �,L.m