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nrrazaa,naava5 tree rnauza SAN J01i;eIIN COUNTY PUBLIC HEALTH SERVICES VIRONMENTAL HEALTH DIVISION (�yl 445 _ SAN JOAQUIN, PHONE (209)462._ 420 t P 0 BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Josquln County for a Permit to construct and/or Install the work herein described. This application is sde in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address T� //1l.Sr'/✓�d'/�fL - City Stbe,,khni Lot Size/Acreage Owner's Name VC4-ty h1t• ?` !;R5 Address //037 .TrCs der t6Cn . Phor>) ' Contractor `VI ( �^�` 1 fllllA seas llOq GGn•l iiai L✓1 604`10rz1j 64 License No. _4TLE?LSL Phos# 0 Gl7 —6 G .3 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION n Out of Service Well n PUMP INSTALLATION ❑ SYSTEM FEPAIR ❑ OTHER ❑ Monitoring Well sat DISTANCE TO NEAREST: SEPTIC TANK —T SEWER LINES DISPOSAL FLD. PROP. LINE /�C FOUNDATION ��. AGRICULTURE WELL F% OTHER WELL_ _ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS s, if C1 Industrial ❑,.5x,O�pen Bottom ❑ Manteca Dia of Well Excavation Dia. of Well Caste FI Domestic/Private yr Other Pack ❑ Tracy Type of Caring_ l Type f Grow •L 1"I Public 17 Other �Oelte Depth of Grout Seal LS Type of Grout 1"v-al �DwIFw I I Irrioatlon _Approx. Depth I I Eastern Surface Saul Installed by brlikil- Repair Work Done LJ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material a Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I Mo septic system permitted it poblic sawn is available within 200 feet.) Installation will urn: Residence _ Commercial_ Other Number of living units: _ Number of bedrooms Character of soa to a depth of 3 feat: Water table depth SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments PKG. TREATMENT PLL n Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE Ll No. 8 Length of lines _. Total length/size FILTER BED n Distance to nearest well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify that I have prepared this application and that the work will be done in accordance with Sen Joaquin county ordinances, slate Laws, and rules and regulatforu of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance or the work for which this permit is issued, I shall not employ any person in such trunner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the folowing: -I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compenu- tion laws of California." The applicant st N for aN requkad apecti ns. C triplets drawing on reverse aids. 77 y Sig 3zL•+_� Title: 1�iz Date:' / FOR DEPARTMENT USE ONLY Application Accepted by f�•"'v�1 Date �+ l� rJ Area A'0' P� s Ph or Grout Ins / f l pectbn by ,M P Date 5 �/ �j Final Inspection by_ D8100, Z- ,7 7 Additional Comments: Iny �3 �• U � Applicant - Return all copies to: San Joaquin County Public Health Servlces • Environmental Health Permit/Servlces Z�p� 445 N Sao Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED C K RECEIVED BY PATE PERMIT PERMIT NO. FH t4.m 08,