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r APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 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 Regulations of San Joaquin County^Public Health Servicess.^� .{- Job Address J �gy'� A ez"e 7 `S ,• City .Sf�G Lot Size/Acreage _$ O,�'& ,Z Oo' i Owner's Name , Me adw-10 Address Phone / Contractor d wn'er - _ __Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK WER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRI ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PRO AREA _STRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom Manteca Dia. of Excavation Dia. of Well Casing rl DomesticlPrivate ❑ Gravel - 0 Tracy Type of Casing__ Specifications I'1 Public -.1-1 ther F! Delta Depth of Grout Seal Type of Grout I I Irrigation ._,.-,Approx. Depth I I Eastern Surface Seat inslatled by- ' Repair Work Done ❑ Type of Pump H.P. _-- State Work Done —' Well Destruction ❑ Well Diameter Sealing Material h Depth Depth Filler Material r TYPE OF SEPTIC WORK; NEW INSTALLATION I i REPAIR/ADDITIO ( l DESTRUCTION No se ystem permitted it public sewer ithin•200 feet.) I ata 'on will serve: Residence_ Commercial,___.... Other Number of livrn Number of bedrooms Character of soil to s depth o Water tab pth SEPTIC TANK ❑ Type/Mfg Capacity ompartments PKG. TREATMENT PLT. ❑ w Method of Disposal Distance to nearest: Well Foundatio Property Lina LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property line SEEPAGE PITS I 1 Depth Size Number SUMPS Ll to nearest: Well Foundation Property Line j z DISPOSAL PONDS ❑ I 1 hereby certify_that.l_have.prepared-this application.and.that the work-will.be-done in accordance-wit h_San_Joaquin county.ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent'a signature oertifies the following: "I certify that in.the peiformance'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:21 certify that in the performance of the work for which this permit is issued,,.l shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed % Title: Date: O FOR DEPARTMENT USE ONLY Application Accepted by 1 -- --- Date Area i Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 7- 4:ema, o •n -- Applicant -.Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DtJE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. INFO CASH F EM 13.20IREV.iiwal 7y / 93-t�v9a