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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION SAN JOAQUIN COUNTY-PUBLIL4�� V"UIN, PHONE (209)468-3420 q/ ENVIRONMENTAL HEALTH V I 009, STOCgTON, CA 95201 STAT C qd 9 SPECIALP1PQWVUXPIR11.9 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 Services. cc Job Address _1 LNAGy YG4J„ City ?�CX')�T�(J Lot Size/Acreage i Owner's Name f I Address S44 A LQ U, S-TbC CA Phone 2 q 303 �-�gbet E CHEW!ICHL P-ANCH(5 COeWVA CA.q�'7LIZ Contractor Address 233 I ( -Fr?,oc� License No. SS�i�-7�' Phone 1-/ - 3 Z TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT Cl DESTRUCTION 11 chit of Service Well 0 P NSTALLATIO SYSTEM REPAIR ❑ . OTHER ❑ Monitoring Well fir( DISTANCE TO NEAREST: EPTIC TANK SO EWER LINES �5 2:1-10'0 DISPOSAL FLO. 4 SD PROP, LINE l AGRICULTURE WELL OTHER WELL PITS/SUMPS �. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L] Industrial O Open Bottom El Manteca Dia. of Well Excavation 10T' Dia. of Well Casing 11 F) Domestic/Private Gravel Pack ❑ Tracy Type of CasingCHLt_D qO Specifications I'] Public I-l'Other f1 Delta Depth of Grout Seal^'GC> I Type of GroutBeKIT„/Clsm -r I I Irrigation 4OApprox. Depth l I Eastern Surface Setif Installed by Repair Work Done L] Type of Pump H.P. State Work Done _ ,W--ell Destruction O Well Diameter Sealing Material i Depth '--pin 'Te S;T Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR! I public sewer is S'i$8��9A` Pd��r��>ts Installation will serve: Residence — Commercial_ Other ENVIRONMENTAL HfIff" Number of living units: Number of bedrooms SPECIAL PERMIT Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Rev Method of Disposal r Distance to nearest: Well Foundation Property Line RECEIVED LEACHING LINE C1 No. 8 Length of lines Total length/size JUL 15 ITZ FILTER BED ❑ Distance to nearest: Well Foundation Property Lina SAN JOAQUIN COUI ITY PU ICES SEEPAGE PITS I I Depth Sire _4 JOA TH 1 slo SUMPS LI Distance to nearest: Well Foundation RO#�d.1MA ,'h nIVISION DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work wilt be done in accornce i state laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: 'V certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature i cenifies 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." i The applics us call for aired inspections. Complete drawing on reverse side. Signed Title: ��T�C-7rCGOLCI(}1 S j Date: `S " IA-)6 (!:-pg FOR DEPAIATMENT USE ONLY Application Accepted by Dare Area y� Pit or Grout Inspection by Date g � Final Insp CU by Data —17 Additional Comments: J, 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 95201 FEE AMOUNT DUCE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO GASH EM 14.241R1N.tiK51 7C ��f �Z—P EH ll.]e V lfJ