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• APPLICATION 0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 149i N PHONE (209)468-3420 � u� TOC%TON, CA X93 — Fpm t 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 compliance with Ban Joaquin County Ordinance No. 5>9 and 1n862,and the Rules and Regulations of San yNJoa/q�uin County PublicHealthHeaalthA Services. of. R-ot , /`=1 / 'Jq qEi RO t rl K-OftL k ��T MJF r- S City L'_'"•r�.0• Lot Size/Acreage Owner's Name ! - Addrestlt:� t �a Phon��`�g�'�Od� Contractor 6266ebQ1lll�r Address SO WC 0.14AZr1lJC7- (4License No.gOp 15166 PhonA#O,-3131790 TYPE OF WELL/PUMP: NEW WELL �I ryltVd WELL REPLACEMENT fW/L41 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Ll (CP ) OTHER Jjl� Monitoring well ❑ 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 {'EEAJ-McNED "ge A_,WS) ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public 1.1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 13 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil 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 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 LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 workmen'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 applicantmu�j call for r lred 'J��P��_tions. Complete drawing on rover" side. t Signed X 2 '—i7 — Title: eJClsetELtif /"LeC/ Date: 7 V FOR DEPARTMENT USE ONLY �z�i� n p Application Accepted by ,{�, Date -- Area!_✓�-�✓Lp�� [. Pit or Grout Inspection by/�� , f ,J�� Date n // Final (Inspection by l L " v Date Additional Comments: !I'I1A/ �9 .A/H S�a��c-cGL! 66/1el AZA A✓A f koL c.f.�-� Applicant - Return all copies to: San Joaquin Coun4ppublle Health ServicLl I es Environmental Health Permit/Services % 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 in Q/FEE 1 AMOUNT DUE AMOUNT REMITTED CA INFO SH RECEIVED BY DATE PERMIT NO. Page IJA EH 13 2�IREV.1/n51 4 EH 1 20 [