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APPLICATION 1" SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 / P 0 BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES I 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 Regulations of San Joaquin County �jPublic gHealth Services. 3 Job Address ` G ! L:._ K 1-4, City Lot Size/Acreage �� Ownar'a Name n� MAddress 12� Ii 7 Phone KContractor •'�� Address �t License No. Phone TYPE OF WELL/PUMP: NEW W L ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATIO O SYSTEM REPA1 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION GRICU WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL P REA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Botto ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gr ack ❑ Tracy Type of Casing_ Specifications I'I Public Other n Delta pth of Grout Seal Type of Grout I I Irrigation —,Approx. Depth I I Eastern Su ce Sedi installed by Repair Work Done ❑ Type of Pump H,P. __ State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION { I DESTRUCTION I I (No seplie system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Y_ Commercial r— Other Number of living units: I Number of bedrooms J Character of soil to a depth of 3 feet: `M Water table depth SEPTIC TANK ❑ Type/Mfg Capacity 12W Add No. Compartments PKG. TREATMENT PLT.❑ x y'� Method of Disposal Distance to nearest: Well Foundation� Property Line X LEACHING LINE 0 No. & Length of lines -3 - 40 otai length/size b [r- FILTER BED 0 Distance to nearest: Well 114 Foundati Property Line 13 SEEPAGE PITS 11 Depth .�.Sr Size Number—11 SUMPS LI Distance to nearest: Well X Foundation 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 Home owner or licensed agent's iignature certifies the following: "1 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 sub contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shail employ persons subject to workman's compensa- tion laws of California." The applkvlt must Cal forrail raqui ed inspections. Complete drawing on reverse side. YSigned X __1.. Title: Data: FOR DEPARTMENT USE ONLY q2 ��Application Accepted by i + Date f �` -y tJ Area f (Pjt'or Grout Inspection Date 2-Z& Final Inspection Data Additional Comments: I-,f 2 Z• Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 9520.1 IFEE 1 'AMOUNT DUE AMOUNT REMITTED CASH ECEIVED BY DATE PERMIT-N O. E . EH 13-2�rREV.iin3� I � 60 EH 14•75 Iff JJ