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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES `�l ENVIRONMENTAL HEALTH DIVISION Qr L (� `�` 445 N SAN JOAQUIN, PHONE (209)468-3420 LJ� P 0 BOX 2009, STOC%TON, CA 95201 No PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C r (Complete in Triplicate) 0 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 Ho. 5 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. �__ � Job Address ©27 �'f (`City Lot Size/Acreage XOwner's Name -'CLJ2 Z� P Address EJ L� — Phone-4 7 I 2- Contractor _^ G Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing it Domestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing_ Specifications C1 Public fa Other l-1 Delta Depth of Grout Seal Type of Grout I I Inigalion —Approx. Depth I I Eastern Surface Seal Installed by r Repair Work Done U Type of Pump H.P. State Work Done /1 Well Destruction ❑ Well Diameter Sealing Material & Depth V i Depth Filler Material & Depth t ' TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION lNo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence — Commercial— Other Number of living units: Number of bedrooms /1 Character of soil to a depth of 3 feet: Water table depth 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 0 PKG. TREATMENT PLT. ❑ Method of Disposal r l Distance to nearest: Well foundation Property Line 1 LEACHING LINE ❑ No. $ Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i A r ' SEEPAGE PITS 11 Depth_' Size Numhai. SUMPS U3 Distance to nearest: Well Foundation ,Property Line DISPOSAL PONDS ❑ '� b 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, 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. I shall not employ any person in such manner as to become subject.to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify 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 Calif6r_�la. The applicant iust c for all r rred inspections. Comofele drawing on ravers e. _ ` Signed Title: Date: F R SPAR Application Accepted by to ~ — 2, Area O Pit or Grout Inspection by Date Final Inspection by Date f Additional Comments: ' Applicant - Return all copies -to:- San Joaquin County Public Health Services Environmental Health'Peribit/Services 445 N San Joaquin, P O Boxe2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7'NO. *'(� + E1113-24 IREV.riMSY i fl� � A, ` ; � a3 — � 1 r £H 14.25 t l .r