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APPLICATION 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 made to San Joaquin County for a permit to construct and/or install the work herein described. This application Is made it ccuplionce vith Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. // ,�., Job Address�� [iu�Ai1 l Z City IZ:�Z Lot Size/Acreage age _ Owner's Name ( -n ,AVIV Address (..!_ . / ye ( -a-E )A)= /T/11Er- Phoneme''111 LJ�'F Loot Contractor NddrtssNr C �Y_�License N2��Sr�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public 11 Other Ll Delta Depth of Grout Seal Type of Grout I I litigation __Approx. Depth I I Eastern Surface Seul Installed by 1 Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material a Depth p0 Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION DESTRUCTION 1 I (No septic system permitted if public Anwar is available within 200 feet) Installation will serve: Residence>I::, Commercial_ Other Number of Irving units: -I-- Number of b�e�drooms !:F— Character Character of sail to a depth of 3 feet: / M�G'R'�- Water table depth SEPTIC TANK g((sy-❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLL ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE No. 8 Length of lines -`e'-7 Total length/size «ice FILTER BED ❑ Distance to nearest: Well Foundation L Property Line Sy SEEPAGE PITS 11 Depth Q2+�.�Irl, Size /� �� Numberd/✓E: SUMPS A'( Distance to nearest: Weil giO•-f- Foundation Property Line S`r DISPOSAL PONDS ❑ 1 hereby csnity 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 agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such mi nnor as to become subject to workmates compensation laws of California,"Contractor's hiring or wb.contracting signature tortillas the following: -I certify that in the performance of the work for which this permit is issued, I shell employ persona subject to workmanl compensa tan laws of California." The applicsn ust cell for all r trued ns tans. C�om/gleto drawing on reverse side. Signetl� ��ZjC/4 / � Title: ' Date: '. DEPARTMENT USE ONLY O, Appli ton Accepted by �Ay�(J„nA L `-h -- -- Date Area Cr De w Grout Fna coon by F"!J .Date Final Inspection by jOWd��`Cal'e 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 95201 i NFFE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMT NO, EH H-l! I