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0 APPLICATION • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby msde,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. o. Job Address 0,rg D City L f Lot Size/Acreage z �f Owner's Name CrVf 6ddress�0'r7�' �`��n..A LP6• S- 109 Phone -0C1—%?:Z—;-03 Contractor CQY6G a0WEi1Cr Address /`i!) nvr+�c- /HAIV/ License No. Ptlortt��a 7f 3�s�0 TYPE OF WELL/PUMP. NEW WELL IIIii WELL REPLACEMENT [Zl-(Et.) DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ Cur)OTHER 6,' Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS &EEkrrAcHo WO.'1L/[lleJS) ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'I Public 1:1 Other 11 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION 1 I INo septic system permitted if public sewer is available within 200 fei Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of and to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE ❑ No. b Length of lines Total length/size -FILTER BED ❑ Distance to nearest: Well Founoation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to neerest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certity 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 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." The applicant nn) tcall for U rest red inss tions. Complete drawing on reverse side. Signed Title: CG7-/Ma'^ �l Date: �� o _,FnfO(nO�7p'TEPARTMENT USE ONLY �i Application Accepted by r `�`�` ��- �"'� \^ Date AreaC U/LA- Ga C's Pit or Grout Inspection by Date/ go Fi al Inspection by Date 9 ..,C Date Additional Comments: 2(/Ia a Lo-r r /7 • 5a Applicant - Return all cops s to: San Joaquin unty Public Health Se es Environmental Health Permit/Services .Q/ 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE 77TP—ERM—,TN0 EH 13.24IAEV.Sixel �� C/ oo u zrs lDl� 38 Page 131 EH I