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' APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ®A Y _ 445 N SAN JOAQUIN, PHONE (2CA)96201420/ REE VL rf P 0 BOX 2009, �. AUS 13 1992 PERMIT E%PIRES 1 YEAR FROM DATE ISSUED SAS\JOA {Complete in Triplicate) �jJ LCWI'ALTTCOi.?! T`7 Application is Hereby made,to San Joaquin county for a permit to construct and/or install the wo crc 8 �'fhis application is made in compliance with San Joaquin County ordinance No. 51+9 and i$b2 and the Rules and 5iegulat� Joaquin County Public Health Services. - U City S�0 1 til Lot Size/Acreage "L'.. 1 Job Address c`G S Phone �� ddress _ Owner's Name S7 25 156 Phone �3�—�� fl�S1.'�! n v �Vlfa,tal � yLS[-�cr�� License Ka. ��-�.-- Contractor y ` Address V 1 NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑�t of Service Well ❑ TYPE OF WELL/PUMP: Mo storing 6ie11 ❑ SYSTEM REPAIR ❑ OTHER��,,t� c. -PUMP INSTALLATION ❑ ' DISPOSAL FLDPROP. LINE DISTANCE TO NEAREST: SEPTIC TANK �L_ pIS . -. SEWER LINES �-�-- FOUNDATION _ Q --__1AGRICULTURE WELL �� OTHER WELL Y'Q PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Open Bottom ❑ Manteca „ Dia. of Wall Excavation ❑ Industrial Specifications [.� Domestic/Private CI Gravel Pack L1 Tracy Type of Casing_ q9 Delta Depth of Grout Seal Type of Grout I`1 Public Pother I I I Irrigation2� Approx. Depth I I Eastern Surface Seai Installed by of Pump H.P. Stat Work Done; Repair Work Done ❑ Type Sealing Material & Depth `t V %A t Well Destruction ❑ Well Diameter Biller Material 8 Depth Iv A � ' Depth 4 TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRlADDITIDN I I DESTRUCTION I I availablerwthin 200 feet.)it public sewer is r installation will serve: Residence— Commercial Other # Number of bedrooms j N1�tber of living units: Water table depth Character of soil to a depth of 3 feet: Capacity Na. Compartments C i SEPTIC TANK ❑ Type/Mfg Method of Disposal PKG. TREATMENT PLT. Cl + Distance to nearest: Well Foundation Property tine Total length/size LEACHING LINE ❑ No. & Length of lines Properly Lina r FILTER BED n Distance to nearest: Wall Foundation P Y SEEPAGE PITS 11 Depth Size _ Number r SUMPS L: Distance to nearest: Well Foundation Property Line J I;' DISPOSAL PONDS Cl 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 i following: "I certify that in the performance of the work for which this permst is issued, I aha not Home owner or licensed agent's signature cenifies the I 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 mus c r al uired inspections. Complete drawing an reverse side. �f _q� Signed XrTitle: �'� Date: SY FOR DEPARTMENT USE ONLY � - � Data Area Application Accepted by - i Pit or Grout Inspection by . Date Final Inspection by Date ' Additional Comments- Applicant - Return all copies to: San Joaquin County Public Health Services T �, Environmental Health Permit/Services I 445 N San Joaquin, P O Box 2009; Stkn, CA 95201 L I F FEECK ECEIVED BY DATE PERMIT'NO. ` INFO AMOUNT DUE AMOUNT REMITTED ITTED i EH 13-24 1REV.I/X 51 EH 14.26