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no PID W APPLICATION SAN JOAQUIN COUNTY PUBLIC HEENVIRONMENTAL HEALT445 N SAN JOAQUIN, PHONP O BOX 2009, STOCKTPERP T & PIRES 1 YEAR FUED(Complete is Tri f �� QCr/it*f Appheat.ion Is her�made San J uin County for a permit to construct and/or install the work herein escr e s application is made in compliance th San Joaquin County Ordinance No. 549 and 1562 and the Rules and Regulations of San Joaquin County Public Health Service 40 /1 _ —- 7 A - Job Address. v � ,r��" ~ Lot Size/Acreage 1= �5�` f - s Owner's N Addresskms.%lr Phone E'er •¢ E ♦ .�L�r'r ;r �./ ..__a: . 7 Contractor = Address �' � 11/!4[��' _ License No. .t �N Phone TYPE OF WELL/PUMP: NEW WELLRU WELL REPLACEMENT ❑ DESTRUCTION b out of service well ❑ PUMP INSTALLATION Q SYSTEM REPAIR © OTHEF O Monitoring.Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES D,,�(�$�AyLF� PROP. LINE f,F FOUNDATION , Z69 I'* AGRICULTURE WELL OTHE�WELL >` r PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , ;I CI Industrial El Open Bottom 0 Manteca. Dia. of Well Excavation Dia. of Well Casing (:l DprrleatiGlPrivate ❑ Gravel Pack 0 Tracy Type of Casing_ �� — Specifications I'1'Public M Oth n Delta Depth of Grout Seal _ � Type of Grout i(Irrigation -i �' p rf Depth I I Eamefn Surface Seal Installed by, Repair Work Done L3 Tyne of Pump H.P. — State Work Done Welt Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public Bawer is AOMM Installation will serve: Rssic)ence_ Commercial_ Other Number of living units. Number of bedrooms RECEIVED Character of Boit to a depth of 3 feet: A P R 43 AVAlepth SEPTIC TANK. ❑ Type/Mfg Capacity ,AIPJAPORR lt& PKG.'TREATMENT PLT. 0 PUBLIC NFeA�tlil>tf sf[I�itpg�p Distance to nearest: Well Foundation Ef�VIRE NNEAT4�hi�il�ll. lllN J LEACHING LINE Cl No. 8 Length of tines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line `jam SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, a rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall o employ any person in such manner as to become subject to workman's compensation law$of California."Contractor's hiring of tub-contracting signatu certifies the following:"I certify that in aha performance of the work for which this permit is issued,I&hall employ persons subject to workman's compensa- tion taws of California." The applicant gg[_):aR o/tdu' _ y tions. Complete drawing on ra ar side. !� Sigma /�- f� f %='✓.% — /x f� K � - Title: Date: ! FOR DEPARTMENT USE ONLY � Application Accepted by �� Date Area Pit or Gr t I spection by Date .Final Inspection by Data�7�/'� Additlonsl Comments: Applicant - Return 1 copies San Joaquin Count Public Health Services pp Environmental Heait_6__R /Services 445 N San Joaqui a 2008, Stkn, CA 85201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED By DfrE PERMIT'NO. IYO, O y , 't . EH ;WWF13-2�[�tY.erns! N-Jq. a' 1 } FH 142& I iii