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nnpT I C""'71 M. ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEA1,TH DIVISION 445 N SAN JOAQUIN, PH NE (209)46$-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 in ccupliance with San Joaquin County Ordinance Be. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address $)�" ��Y �Q �l*KyK LcAr� City Lod' Lot Size/Acreage � 1 > - ark Ir�octc k ) i Owner's Name 6�J►'}/�WrLe + Address !iL Sore) ,C R 11 CA q y-4O Z Contractor ` r} J r Ss i Address -46 W• D C » CA License No. C57 t 9-cdl) Phone Lam-3043-ZZ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Out of Service Well ❑ i PUMP INSTALLATION ❑ SYSTEMA PAIR ❑ OTHER ❑ Monitoring Well y{ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL 1 PITS/SUMPS4s400,, CA .f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC ION SPECIFICATIONS I��6r�17or-�Wet1 )►►W'le"' ® Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation.__ -_8' Dia. of Well Casing Z !' f.1 Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Cas�ing_ *S "Scl.lita Specifications f'1 Public other)fVI~4,,o n Delta Depth of Gr ut Seal - ".k _ iGft � -� Type o} Grout e'w fe u I I Irrigation L Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done w Well Destruction 1 Well Diameter Sealing Material i Depth d 2 Depth hiller Material i Depth o [ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION f I lNo septic system permitted if public sewer is available within 200 feet.! Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table depth J SEPTIC TANK. O Type/Mfg Capa ity No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well Founclatior, Property Line LEACHING LINE ❑ No. IS Length of lines Total length/size i FILTER BED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundatio Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 subcontracting 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 California." M J]��• W��1 W �, 1?��e c The applicant must call for all required inspections. Complete drawing on reverse sic e. 111— (kV.L-40 9-)f-els, Signed X Title: «u Date: FOR DEPARTMENT USE ONLY / q c Application Accepted by c} Date ! ``-� Area Pit or Grout Inspection b / q � y Date�� Final Inspection by Date i Additional Comments; Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permi /Services 445 N San Joaquin, p O Sox 2009, Stkn, CA 95201 CK S lNFq AMOUNT DUE AMOUNTTREMITTED CASH RECEIVED eY �j DATE // PER'MM NO. II . EH 13.24 IREv.t/r sj t!/ 4 ! ( 1 ?✓U0 EH 14.76 C!/ ..J