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APPLICATION I SAN s,.JAQUIN COUNTY PUBLIC HEALTH zARVICES ENVIRONMENTAL aEAI1TH DIVISION j 445 N SAN JOAQUIN, PHO E (209)468-3420 P O BOX 2009, STOCg ON, CA 95201 PERMIT EXPIRES 1 YEAR ROM DATE ISSUED (Complete in TrEplicate) 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 cotapliaice with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 7�jo �✓f Job Address 707 �`' /OSe�lr �ve' icy `�It Lot Size/Acreage 3/� acre Owner's Name/ 'Alr L—, Po,t-feS Address 7o7 v. 4�PMr' Phone 3463 olgff Chafe, S iic 8 Contfactor V � y�+ lh� rAddress ,Iko A Ch 957fAZ License No.5 9(' Phone(rflt 631~9S' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL — OTHER WELL--=— PITS/SUMPS Ib0' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial ❑ Open Bottom Manteca Oia. of Wel Excavation i>tG Dia. of Wall Caain Z`f �'DomesticlPrivate LK Gravel Pack C7 Tracy Type of Ca ing_ PUG Specifications J I"I Public is Other 171 Delta Depth of G out Seal KPOPeg iV (Type of Grout I I Irrigation �Appro■. Depth I I Eastern Surface Sal Installed by 0 F::- 126IL4 -- Repair Work Done L7 Type of Pump — H.P. "' State Work Done W0 Destruction ❑ Well Diameter 2—IMG4 Sealing Material Depth Depth __ 0 - FIller Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/A OITION I I DESTRUCTION l I tNo septic system permitted if public sewer is available within 200 feet.) 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 ❑ Typal Mfg \Flulaion city No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Property Line LEACHING LINE 0 No. dr Length of lines Total length/sire FILTER BED ❑ Distance to nearest: Well Fo\04ocation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Faun i on Property Line DISPOSAL PONDS ❑ 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 Mame owner or licensed agent's signature certifies the following: "I comity that in he 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 sub-contracting signature certifies the following: "I comity that in the performance of the work for which this rmit is issued. I shall employ persons subject to workman's compensa- tion taws of California." The applicant muWealxalluired inspeetions. Complete drawing on reverse ide. Signed x C ' 17. Title: �eo�d 1 S Date: 7 oZ J.�3� FOR DEPARTMENT USE ONLY !�;l Zcf Gv Application Accepted by ^ Rate Arae Pit or Grout Inspection by Date Fin I Inspection by flats Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Per it/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMO�U+NNTARE/M)ITTT'�ED CASH RECEIVED Ely DATE PERMIT'NO. Page 7 2 . EH13.74IREv.�i�al c :/('L/l.f LL(P :7� 1J Elf 11.71! J �i/