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PERMIT EXPIRE-b 9 APPLICATION SR �p1 r /`' ak�.Alllil Permit may have expired without OENVIRONMENTALAQUIN COUNTY PHEAT THUBLIC HDIVISI TH <W, T work being completed orinsp �N SAN JOAQUIN, PHONE (209)46 G O BOX 2009, STOCgTON, CA 95 by Environmental Health Division �� PERMITS 1 YEAR FROM D SUED' e (Complete in Triplicate) 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 Coun^t�•�O,rdinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health 9erYicea�p//��1 —ag Job Address J �S &,4-'Dr Ivo / C��"' City AC41 Lot 81ze/Acreage Owner's Name Y14�`7;7 R s C Address �2 _ G 7 +S-r�•r7L/�Q/"MY P—D Phone Contractor Zi&Z&J&;t-Address gaa S •� !��/.�CLAEpnse N0._51ZA9ZAr Phone Z 0 TYPE OF WELL/PUMP: NEW WELL WELL. REPLACEMENT F) DESTRUCTION El Out of Service Well ❑ V PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ Monitoring Well ❑ OI STANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. — PROP. LINE FOUNDATION AGRICULTURE WELL � OTHER WELL === • ,PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ] fl Industrial ❑ Open Bottom 11 Manteca Die. of Well Exc Ilion Dia. of Well Cas' g Cl Domestic/Private 191 Gravel Pack C,$%Tracy Type of Casing Q_Sl�� Specifications imf&. I•I Pubtic (1 Other (l Delta Depth of Grout Seal //Al lrw�r , Type of GroW�r�� �!Jrngation Approx. Depth l I Eastern Surface Seal Installed by (� Repair Work Done 0 Type of Pump H.P. —_ State Work Done Well Destruction Cl Well Diameter Sealing Materiel i Depth Depth Filler Material i Depth " t TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIRIADDITION I I DESTRUCTION ( I (No septic system permitted if public sewer is ` available within 200 feet.) r/�v Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water PAXM SEPTIC TANK ❑ Type/Mfg Capacity No. Alift TU PKG. TREATMENT PLT. ❑ Metho�lgbpiapq�al Distance to nearest: Well Foundation Property l,ifreJp� JJjA�1NV QUIN CQf INTV LEACHING LINE ❑ No. b Length of lines Total len ntf$L ��1 I S�R�t FILTER BED �f Distance to nearest: Well Foundation Property Line111, �fl1y�jl0 \\ SEEPAGE PITS 11 Depth Size 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 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 of sub-contracting 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 applica st llr all rTuirAd insPections. Complete drawing on re se side. Signed Title: Date: /�•j FOR DEPARTMENT US NLYy/ Application Accepted by �_ Data r� e Area Pit or Grout Inspection by Date Final Inspe do y Da Additional Comments- sy Applicant- Return all copies to: San Joaquin County Public Health Service9/ Environmental Health Permit/Services j,) 4ic445 N San Joaquin, P O Box 2009, Stkn, CA 95201!NF FEE I AMOUNT DUE AMOUNT REMITTED C RECEIVEp 8Y DATEjo,�, r� J� �� EH 13.24(REV.t/451 pC) O EH 14->a UUU""" VVV 10