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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby mile.to San Joaquin County for a permit to construct and/or install the vork herein deacsibed. This application is mate in compliance with San Joaquin County Ordinance No. 549 and 1862 and t Rules and Regulations of.San Joaquin County Public Health Services. r,�_ Job Address °^ Q City' t Size/Acreage V r �s Owner's No" O VSAddress f-0ye))e .O of o X ONC Phone A 7frt o 7 F oYp Contractor Address � License No.1-11AQe .Phone Jr / TYPE OF WELL/PU- P: 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 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia.of Well Excavation Dia, of Well Casing 11 Domestic/Privet* ❑ Gravel Pack7 ❑ Tracy Type of Casing Specifications 19 Public I:1 Other f7 Delta Depth.of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by t� Repair Work Done ❑ Type of Pump H.P. State Work Done_ r� Well Destrucijon ❑ well Diameter Sealing..Materials Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION 11 (No seplic system permitted it public sewer is J le,,f'1,q available within 200 loot.) Installation will serve: Residence_ Commercial�x�EY'rO , Number o/living units:_ Number of bedrooms Character of acts to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Cap wity iift Q No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal a Distance to nearest Well/010 Foundation �� Property Line 3 . LEACHING LINE ❑ No. &Length of linea A. W O Total length/size SPOr FILTER BED ❑ Distance to nearest: Well 1� /y,�r �_ Foundation l°faH_ Property Line g S _ SEEPAGE PITS I I t DePth ,� S Size /� 73f.3- Number' `� SUMPS 't1�Distance to nearest: Well &11 Foundation ZC Property Lina DISPOSAL PONDS ❑ 1 hereby comity 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 certifies the following: "I comity that in the performance of the work for which this permit is issued,I.shelf not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor'ahiring or 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 applicant must call for all rerSriFey inspsctanc. Cgmplate drawing onreverse side. Signed X �� /o l C //�7yd'iGfJ'/{' Title: _f„�=)y Date: �LQQ_LS. FOR DEPARTMENT USE ONLY r� lc len Aeecc�eepted by t Date !'Iq X Area�1 L L P' or rout 12ctWn by of - Final Inapecponby:T- "�"/��*s-a Date �/ Additional Comments:�� .a�,,� ,�� /.�;f / ��i G� t,, JT� �� Applicant - Return all copies to: San Joaquin.County Publ c Health,Hervices Environmental Health Permit/Services l 445 N San Joaquin,. P. 0 Box 2009, SLku,.CA 95201 MFO AMOUNT DDE AMOUNT REMITTED. Arty RECEIVED BY DATE PERMIT NO: .,EH rw•24 t11aEV.rrx lir I,N' O C� - 4. ` �✓' ��;_ '/ y'�.