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APPLICATION. SAN JOAQUIN COUNTY'PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,.PHONE (209)468-3420 P 0 BOX 2009, ST.00KTON, CA 95201 v\ PERMIT"ERPIRES 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatione'of San Joaquin County Public Health Services. /i/� " 1. / % •' ,.�. R �/\ 1:... �'i F4 T-+.. .Si 9.P/A[rA"P t�---��//�� /� __-- - � • . - Owners, Name• 1k; �t lelEAL Address --�hM "PhoneZZ 44,a6lor Address �/'Y • YV� /�/ wi[ icenserNo.��f- ' Phon TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ('I Public 1:1 Other 171 Delta Depth of Grout Seal Type of Grout I I Irrigation __-_ Approx, Depth I I Eastern Surlac9 Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material Z Depth TYPE OF SEPTIC WORK: ,eNEW INSTALLATION (I REPAIR/ADDITION DESTRUCTION I (No septic system permitted if'public sewer is available within 200 feet.) Installation will serve: Residence"A Commercial Other Number of living units: -/— Number �of bMedro�om�^s�' Character of soil to a depth of 3 feet: Vii- Water table depth SEPTIC TANK .JE�U67-b Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ { r Method of Disposal, Distance to nearest: Well, ;Foundation Ptoperty Line r....... ;. y / LEACHING LINE X No. &Length of lines �_ Total length/size FILTER RED ❑ Distance, to nearest: Well .AO- Foundation_ Property Line SEEPAGE PITS..''° Depth a� Sire ` " " Number / —� SUMPS LI Distancg''to nearest: Well 14542,;.Foundation —.� Property Line z�.,�� DISPOSAL PONDS ❑ I hereby certify that 1 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 must call for all required i ons. Comple , 'drawing on reverse side, -'Sign" pate` FOR DEPARTMENT USE ONLY Application Accepted by �� WP Date �"� /y L Area Pit or Grout Inspection by /I�// Date Final Inspec7ti6n by Additional Comments: �614h"/ Applicant - Return all copies to: SanfJoaquin County Public Health Services ~� Env ronlmental Health Permit/Services 445 N San Joaquin, P O.Box 2009,.Stkn, CA 95201 . . EH 13Q4IREV, ring EH 14.20 Date FEE INFO AMOUNT DUE AMOUNT REMITTED ASN RECEIVED BY DATE PERMIT'N0. ��-X0