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SAN All COUNTY PUBLIC HEALTHVICES V I RONMENTAL HEALTH D I V I S I ,��,/�i SANJOAQUINCOUNTY-PUBLI6 OUIN, PHONE (209)468-3420 �lllr� ENVIRONMENTAL HEALTH V I 2009, STOCBTON, CA 95201 ST/�' fC =lj 90 0 6 r s I SPECIAL PTMMITIPIRES 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 in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �^ Job Address 14y �R/JHAW 1121-0City JTC�%�TDIJ Wt Size/Acreage Owner's Nome OSC/A D(US1 Cir Address 14U O, SOA tQ fi. ,T0 0jJI CA Phone - 9 -303 1�L"b t e= R61M 1C NLILACVCHp coleAovA CA. `?s7 IZ. Contractor62G--,7 HAzrnra'T Addressam�n License No. LSi3 q Phone S/6-,63E-7Z,76 TYPE / 63 -7i- TVPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ CEPTIC INSTALLATIO SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: TANK 'C s0 EWER LINES /5 C7 DISPOSAL FLD. 'G5 PROP. LINE 2' d AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y II ❑ Industrial ❑ Open Bottom ED] Manteca Dia. of Well Excavation I(D I' Dia. 01 Well Casing � Cl Domestic/Private 'Gravel Pack ❑ Tracy Type of Casing 5CHl5j> go PLfe. Specifications 1'1 Public ❑Other n Delta Depth of Grout Seal�6d / Type of Grout 1RENit zcls lb -7-Q I I Irrigation 'IO-Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Wall Destruction ❑ Well Diameter Sealing Material i Depth \ LvJ 7_L=-ST Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/Ji. 17�Nr{i�Tlle@F4FdPIJBIsi�b1Mlispublic sewer is J JJ ��E�N[VI IRONMENTAL HAyff"r"'"Mloet.1 Installation will serve: Residence_ Commercial_ Othar Number of living units: _ Number of bedrooms SPECIAL PERMIT Character of wil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. compartments PKG. TREATMENT PLT.❑ Method of Disposal PAVRAENT Distance to nearest: Well Foundation Property Line RECEIVED LEACHING LINE ❑ No. g Length of lines Total length/size JUL 15 IN FILTER BED ❑ Distance to nearest: Well Foundation Property Lim SAN JOAQUIN COUNTY F ICES SEEPAGE PITS 11 Depth Sirs ANJOAQj TH IViSlO SUMPS LI Distance to nearest: Well Foundation ��rIROARAT.TH IVISION DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in actor ante h i state laws, and 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, 1 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 certify that in the performance o1 the work for which this permit is issued, I shall employ persons w arl'�11p�Ds�J tion laws of California." SlilF iifta'�—+}J1V The applic(aftTlus/S,,call tor�all-required inspections. Complete drawing on reverse side. / Signed X // I.�� J � Title: Data: a2 f-1 � Lav6t7Sn,V S�Oc. FOR DEPARTMENT USESEONLY p. Application Accepted In f� Date C y Area JJ,�11 Pit or Grout Inspection by Date g 27i Final Inspectio by Date �Z Additional Comments: I tel_ C-0 Z .S(o'CC,�r3 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services / 15 r 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BV DATE PERMR'NO. EH 13'24(REV.r/Kar V 7-4 H 1420