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4�) APPLICATION .�n r SAN JOAQUIN COUNTY PUBLIC j NENTAL HEALTH 445 SANVROOOAQ IN PHONE P O BOX 2009, STOC%TON 201 N '�WPERMIT EXPIRES 1 YEAR FR ISS (Complete in Trip n Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This appllC&tiOn is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules said Regulations of San Joaquin County Publ4cc Heaaljlth1Serv1 /} ,p Job Address `� /.`/��( '/� ^r Z/SC C t City U; .Bnn Lot Size/Acreage �Pr Owner's Name �)2(,v.. � ��Z7 Address Phone ; Contractor SDS �� Addr� — License No Phon TYPE OF WELV PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIOWCD Out of Service Gell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C 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 rry\y ❑ Industrial ❑ Open Bottom G Manteca Dia. of Well Excavation Dia. of Well Casing -0> Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications i'1 Public ❑ Other I7 Delta Depth of Grout Seal Type of Grout � I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed bye/') i Repair Work Done L3 Type of Pump H.P. State Work Oona_ Well Destruction ❑ We"Diameter Sealing Material a Depth Depth f Filler Material 4, Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION Af DESTRUCTION 11 (No septic system permi:7; available within 200 feet Installation will serve: Residence •,CommercialeI Other Number o1 living units: � Number of bedrooAems Character of sok to a depth of 3 feet: �^,AdeTeLV h �2 Water table depth SEPTIC TANK ❑ Type/Mfp /T Capacity No. Compartmenn PKG. TREATMENT PLT.❑ Method of Disposal rwerea y, Well Foundation Property Lim LEACHING LINE J{r No. 6 Length of lines Cnp /10 Tolat length/size �S^l FILTER BED ❑ Distance to nearest. Wel— Foundation Property Line SEEPAGE PITS If Depth 7 S` / Size 4V ''I Number A)0,0 SUMPS CI Distance to nearest:_. Well Z75,' Foundation� Property Lim DISPOSAL PONDS ❑ t 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 rubs and regulation,of the San Joaquin County Homeowner or licensed agent's signature certifies the following: '9 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 workmen's compensation laws of Cakforma."Contractofs hiring or sub-contracting signature certifies the foaot5r,'nq certify that in the Performance of the work for which this permit is issued. I shall employ persons subject to workman's cempenaa. tion laws of CeIHo'lMa. The applicant must aK fw all ins tions. amplete drawing on reverse side. / S Title: /t�.n Q /a-17-+� Date: FOR DEPARTMENT USE ONLY Application Accepted by Dote Pit or Grout Inspection by Data Final Inspection by 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 9 01 6-,P,Poo I-Z1C f FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE INFO /�)� ASN UA/ E l� . em 11],IaEV.,,hal , VV A EM ta10