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APPL•IC.�TTnN , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES EIVIRONMENTAL EMIaR ,DX_ V,SION i i f c� 445 N SAN JOAQUIN, PHS s� P O BOX 2009, STOCCIt ;`CA h900 Q� �{; PERMIT EMPIRES I YEAIA 'F�fiD 2��IIID (Complete in Triplicate) C Application is hereby made.to San Joaquin County, for a Permit to construct and/or instau the work herein described. This application is made in co=pliance with San Joaquin County Ordinance No. 549 and 1862 aatd the Rules and Regulations of San Joaquin County Public Health Services. 7 Job Address City +-}- Lot Size/Acreage Owner's Name �, -ISI, Address II Pi►one r QC.`�'Vi' Address��-S�G�Sr �ter`�nse No.S� � Phan �Z Cantracro ' TYPE OF WELL/PUMP: EW WELL WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Ke.0 ❑ y PUMP INSTALLATION ❑ SYSTEMgEPAIR ❑ 0 ER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. / PROP, LINE N/'1 R WELL OTHER WELL /" PITS/SUMPS FOUNDATION >u AGRICULTURE INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation__Q5 IriC� Dia. of Weil Casing Type of Casing- G- Specifications Domestic rivate �Gravel Pack ❑ Tracy 4-� -7-�---- i'i Public fel Other rl Delta Depth of Grout Sea! Type of Grou CN T l 1 trrivadon �jaApprox. Depth l I Eastern Surface Soul installed by Repair Work Done L3 Type of Pump H.P. State Work one Well Destruction ❑ Well Diameter nB Maierial Depth _ v1�`srn -9 cr Depth Filler Material & Depth .w I TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAiRlADDITION I I 'DESTRUCTION l I (No septic system permitted it public sewevs available within 200 feet.) Installation will serve: Residence_ Commercial, Other Number of living units: Number of bedrooms 1 Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal i Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Lina i l SEEPAGE PITS 11 Depth Size Number iSUMPS Li Distance to nearest: Weil Foundation Property Line j DISPOSAL PONDS ❑ 1 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. 1 shall not employ any person in such manner as to became subject to workman's compensation laws of California." Contractofs 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 persona:subject to workman's compensa- tion laws of California." The applica ust all for all required ' pections. Complete drawing on raver Signed X �`"'z� Title: r Date: FOR DEPARTMENT USE ONL Application Accepted by � Date ^ Area Pit or Grout Inspection by Date Final Inspection by Data a� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO L AMOUNT DUE AM[`OUNT REMITTED �(}C�ASN AECEiVED 8Y GATE PERMIT'NO. 14-25 i1ttY. />,e! p V� V�"�� 1� I 14-25 _ "ti1