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R e-OpT IC„t' Q'; Ft SAN JbAQUIN COUNTY PUBLIC HEALTH b':.RV I CES ENVIRONMENTAL HEALTH DIVISION "� .•;- # ; ' 445 N SAN JOAQUIN, PHONE (209)468-3420,`; ) :r'_ - ' P O BOX 2009, STOC TON, CA 95201 PERMIT EXPIRES 1YEAR FROM DATE ISSUED; `� SEP 2 2': (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to a nstruct and/or install t�evo, orkk herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and"RegunAtiona`o:f-San -- Joaquin County Public Health Services. Job Address $/ �� K8 7Tr �C w� �-a"`� ity �"od ' Lot Size/Acreage Owner's Name 1 C "`G-r'��-�T Address )l -PJ JE S+e--Q �rnc`T*`:?hone C-A C1 440 7— Contractor �t 3 �3C4ia Address Z15 W• 041' `jLA License No. C� 053 Phone _!8-Z2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION X0ut of Service Well L7 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ls( DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL—`-PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J1t6r+tTor�i.ve r t 1►t w-m"� � I n Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel Excavation Dia. of Well Casing Z 1:1 Domestic/Private 0 Gravel Pack ❑ Tracy Type of Ca ing 2�"-5-k P)C};L Specifications 1'1 Public OtherMv'Y.-,� f� n Delta Depth of Grout Seal ._ Type of Grout ax i e CsYa«} Fi,ti. �,., . I I Irrigation y0 Approx. Depth I l Eastern Surface Satil Installed by Repair Work Done L7 Type of Pump H.P. State Work Dona_ Well Destruction F Well Diameter Sealing Material A Depth e+.” 42sL Depth Filler Material i Depth I brr TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/AOOITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) F71Installation will serve: Residence_ Commercial __„_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth .FSEPTIC TANK p Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundatio Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS L) Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 f 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 workmen's compensatiol 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 California." l 1 � 1A'.¢.)! rbf L.c: - (o j 17-¢k-t.c 4-., The applicant must call for all required inspections. Complete drawing on reverse side. Pitt,, Signed Title: bQ'e v2 recd I a l Data: FOR DEPARTMENT USE ONLY 121? Application Accepted by /� ` C Date c�y� / 2 < Area Pit or Grout Inspection by_,4I t , Date -Fln �J Final Inspection by /`2 Date / r' ditional Comments: Fi Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Perm t/Services 445 H San Joaquin, P 0 Bok 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO.