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APPLICATION il SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES .� 445 N�SVAN JOOAQUIN, HONTAL TE (2J ,#, 00 7X-3 P O BOX 2009, STOC%TON, # / PERMIT EXPIRES 1 YEAR FR U/ (Complete in Triplic �—► Application in hereby made.to San Joaquin County for a permit to can truct e work berelar yfe lied. This n..r__ _applleetloa Se made Sn Coegrliance vSth Sen Joaquin County Ordinance No. 519 ''Joaquin County P/uub(lii-c Health Services. yAff �/�///�Job Address( _ —.�� PIPli) �� '/'�-{\-�` C'tyLot Size/Acreege�./i�) •^/��f IJC) �3� PhorKrt� / ZJ2 Owner's Name/ + '�'L[-�M L�•1� i kAdrass r� �.—.-- Contractor Address License Not i *'/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION _ AGRICULTURE WELL OTHER KNELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation_ Dia. of Well Casing Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type o1 Casing___ Specifications I'I Public I1 Other Il Delta Depth of Grow Seat Type of Grout - 1 I tm0ation _Approx. Depth 1 I Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material a Depth Depth Filler Material Y Depth TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION I I OESTRUCTION I I INo septic system permitted it public sewer is available within 200 leat.l Installation will terve: Ro/s,(dance_k Commercial_ Other Number of living units: J— Number of Broom$ -1 '�a i Character of wit to a t of 3 feet: r ^ J/1 ill Water table depth SEPTIC TANK Type/Mfg VNl Capacity No. Compartments ��— PKG. TREATMENT PLT. ❑ /VI ! / Method o1 Disposal N Distance to nearest: Well Ar^" + Foundation&S� Property Line 10 '0` Pff do LEACHING LINE No. b Length of lines _ -2 V &M jV0 Total length/size I a I FILTER BED ❑ Distance to nearest: Well ll r Foundation �. _t Property Line _ SEEPAGE PITS I I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 cenify that in the performance of the work to+which this permit is issued, I shall not employ any per such manner as to become subject to workmen's compensation laws of California."Contractor's hiring or subcontracting signature certifies the f wing. "I canifylshas.i the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenu- tion laws o MHOrnla" The appli nt must all 4014 or`r uired ins Ction ort a drawing on reverse side. Signed Title: Data: . `rR FOR DEPARTMENT US ONLY Application Accepted by Date Area I. '' �' Pit or Grout Inspection by r^,,tvW� � Data Final Inspection by a"""Daco� Additional Comments: W � "'�' V' ✓t-�""� `'� Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Bon 2009, Stkn, CA 9520 FEEl AMOUNT DUE AMOUNT REMITTED I CKRECEIVED BY GATE PERMIT'NO, IN C,,",, . EH 26 IREV.�raer5 EH u a