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�e 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 trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the ]Rules and Regulations of San Joaquin County Public Health Services. Ir ) Job Address �Wu� kp" �., � City L02>/ Lot Size/Acreage f-j Owner's Name �� + � .-- Address 3e3k Phone 31i3`/��S Contractor " Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION-❑�/�t of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER OGS9z ll 97 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. //PR��OPL�•LINE++ ,O,r�1�[1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ��✓ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom 0 Manteca Ria. of Well Excavation pia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public CI Other 1 1-1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I 1 Eastern Surface Sedt Installed by Repair Work Done 0 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth T Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is pV available within 200 feet.) W Installation will se Residence _ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 fee . , Rater table depth SEPTIC TANK. ❑ Type/Mfg I Capaci No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: . Well> Foun Property Line LEACHING LINE ❑ No. & Length of 1i Total long y FILTER BED ❑ Distance t crest: Weft Foundation Property Line �y C SEEPAGE PITSDepth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOS4CPONDS ❑ 't 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 Sen 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 empioy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring of subcontracting signature i 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 inspections, Complete drawing on reverse side. Signed X- . .��.tJl22 Title: &4122UJ Date: FOR DEPARTMENT USE ONLY i Application Accepted byDate Area -.2/ Pit or Grout Inspection by Date .Final Inspection by Additional Comments: 01J AEM14a .2 /O r Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Servicesf t f[C!r¢ e ' 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 t /Q INFO FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY PATE PERMIT'NO. . EH 13.26 TREY.i i A 51 l ��'v � . Bs—o EH s♦-26