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APPLICATION y SANOJQaraUIN COUNTY PUBLIC HEALTH�BRVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 ��OG G��:1✓' " P O BOX 2009, STOC%TON, CA 95201 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made San Joaquin County for a permit to construct and/or install the work herein described. This applicatioq is a Sn c ance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaqu CotulAn , learn Services. y1U l —' \U -�j{r �� ob Address i Ci y Lot Si z /Acreage r"1 C �'T �C4�04 � Owner's Name 1 I MC none ! 0-1 Sp Contractor PITT w 4, 0 Address C License No. Phone `t S �. II TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ (i) 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 If 0 Industrial ❑ Opon Bottom ❑ Manteca Dia. of Well Excava 1uon yr Dia. of Well Casing _ N1 Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ T� Specifications I') Public 1-1 Other fT Delta Depth of Grout Seal ( Type of Grot I I Irrigation —Approx. Depth 1 I Eastern Surface Soul Installed by C.elmen l' , ro Repair Work Done ❑ Type Of Pump H.P. _ State Work Done_ Well Destruction ❑ Wall Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of Ivt : _ Number of bedrooms 1 Character of soil to a depth t: _ r'tabia depth — SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments PKG. TREATMENT' PLL ❑ Method o1 Disposal Distance to nearest: Well n Property Line LEACHING LINE ❑ No. R Length of line Total long FILTER BED ❑ Distance to est: Well Foundation Property Line SEEPAGE PITS Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina 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 workmen's compensa- tion laws ' rola." The a licant mu t call for all equir ins ctioo . Complete drawing on reverse side. f^ Signed Title: �y7 ` Date: ` S FOR DEPAR HENT SE ONLY 19 Application Accepted by k Date Area . Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: — Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services ✓7 445 N San Joaquin, P O Box 2009, Stich, CA 95201 FEE I AMOUNT DUE AMOUNT REMITTED I CASN RECEIVED BY DATE PERMIT NO. INFO . EH Id.241REw.Irxal EH 1429 1