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APPLICATION N COUNTY PUBLIC HEALTH SERVICES S WOE- RONMENTAL HEALTH D I V I S ION EI �/"I Ok?ENT"3 ' 445 N S JOAQIIIN, PHONE (209)468-34 ,' 209)468--34 c 1E �f f B % 2009, STOCgTON, CA 95201 1 ��,�'L'!f,'E ` FAC t PERMIT EiPIRES 1 YEAR FROM DATE ISSUED '7 Pry 2: 6 A�C� (Complete in Triplicate) A 1�lsYJ oa u1n County for a permit to construct and/or insta.LL the work herein described This aAnte with Sen Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health services. Job Address t�to s �• Air- e e-t s, City !Aogdo& Lot Size/Acreage 1 Sfil Owner s Name &.4. 6<J[+w CO Address3z.11 � Are- &m'ti to gs$/7Phona /G r3 Qcr�rn►�y l�rste g� 3aa gg0g4;h [s�o)4bZ-holo Conuictor ASS;Odl ..•fe-f Address S License No one ' TYPE Of WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Kell 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well I DISTANCE TO NEAREST SEPTIC TANK A--- SEWER LINES DISPOSAL DISPOSAL FLD�w/�,,�'� PROP LINE ± 3d ' FOUNDATION - ��- AGRICULTURE WELL IY�_._ OTHER WELL-&A-- PITS/SUMPS !� A' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �! C1 Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dra of Wall Casing Z n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Si�.� � Specifications ' �..e..r I 1 Ptiblrc Cl Other f'l Delta Depth of Grout Seal 2-� Type of Grout I I Irrigation Approx Depth I I Eastern Surface Soul Installed by ' Repair Work Done U Type of Pump H P State Work Done Wail Destruction ❑ Well Diameter sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet 1 Installation will serve Residence— Commercrat Other Number of living units Number of bedrooms Character of soil to a depth of 3 fest Water table depth ' SEPTIC TANK O Type/Mfg Capacity No Compartments PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well Foundation Property Line ' LEACHING LINE Cl No & Length of lines Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Line ' SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest Well Foundation Property Line DISPOSAL PONDS ❑ ' 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lows, and rules and regulations of the San Joaquin county Home owner or licensed agent's signature cenifies the following 'I cartrfy 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 ' carttfies 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 applican ust call foral r �ir inspections Complete drawing on reverse side ' sig Title FOR DEPARTMENT USE ONLY Application Accepted by Date_� � 9 Area ' Pit or Grout Inspection by Date Final Inspection by Date aditional Comments ' Applicant - Return all copies to San Joaquin County Public Health Services 3s Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO INFO CASH Im 13 24 IpEV iins) 00 EH U 26