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APPLICATION SR # SAN JOAQUIN COUNTY PUBLIC HEALTH Ptrbcws ENVIRONMENTAL HEALTH DIVISI 445 N SAN JOAQUIN, PHONE (209)4 8=242 P O BOX 2009, STOC%TON, CA 9 2 Q, W PERMIT EXPIRES I YEAR FROM DATE _ sq / y (Complete in Triplicate) y Application is hereby asede.to San Joaquin County for a permit to construct and/or Install the work herein described. This application Is aade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Snn Joaquin County Public To Services ) /�/''� Job Address 'l I� `r o W `r"' � City�.,_,_,ff Lot Size/Acreage �(�p��/ /}((I r �_ A�dross V Phone36R �`r ' Owner's Nam ��_�� - Contracto Rrzzk ess511. Sew-J'0 License No.727"T Phone S& / ji TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I. DESTRUCTION Ll Out of Service Well ❑ l PUMP INSTALLATION fPA SYSTEM REPAIR )I OTHER ❑ Monitoring Well ❑ , r---DISTANGE-T-0:NEAREST:ISEPTIG-TANK :zz - -_—SEWERLINES- z; --DISPOSAL-FLO:- --PROP.-LINE -- -"s 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 BQ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I Il Public ❑ Other n Delta Depth of Grout Seal Type of Grout II I I Irrigation _ Approx. Death I Eastern / uriaee Seal installed by Repair Work Done 0 Type of Pump �V H.P. �P.)" State Work Done Well.Destruction 10 Well Diameter Sedlltlg•Uliterie.l L Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I Me septic system permitted it public sewer is available within 210 leat.l Instaastion will serve: Residence Commercial_- Other Number of living units: _ Number of bedrooms Character of end to a depth of 3 feel: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments L� PKG, TREATMENT PLT.❑ Method of Disposal `- Distance to nearest: Well Foundation Property Line \ LEACHING LINE ❑ No. d Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS J 11 Depth Size _ -- Number ^SUMPS= CIy,•Distance to neerest:_._,k.Well -.Fo�nd4i9n_ Property Lina DISPOSAL PONDS ❑ - y 1 hereby cenify that I have prepared this application andthatthe 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 cenifies the following; '9 canny 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 subcontracting signature ' certifies the following: "I comfy 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 1must call to IT required inspections. Complete drawing on reverse side. Signed K-- Title: Data: .fL'�_ 1\ FOR DEPARTMENT USE ONL Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by. Date 1 6 .3 Add'dlonel Comments Applic t - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 .5Y ' FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO, ER 1234 IREV.v e al v` 1 r 1 EN u,A