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APPLICATION V t/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRON?1ENTAL HEALT$ DIVISION 445 N SAN JOAQUIN,. PHONE (209)468-3420 P O BOX 2009, ASTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ((((((_��_ Application in hereby made to San Joaquin County for a permit to construct and/or ins the work herein described. This application is made in compliance with San Joaquin County ordinance No. 549 and 1862 the Rules and Regulations of San Joaquin Coua ��}�c Health Services. t7Q— 2`Ob ' Job Address _ /4e f'o viJJ r I✓e_ ( City Q OL k'l0 k1 Lot Si ze/Acreage's' g Gcres Owner's Name rrtie,f:ee By,-c,4 C�rvtD�1`r1PSAddress 1 �vt Plcr,- -3t, rf, /NO b 3/Id Phone Grourto(Waier �-' ��JJ c 9Cq q4920 �5 Contractor -Techni(iInc Address o 0 -7 ,tChlco i flvv License No. 3 Phone /7/•-?.38 TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Yell DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E7 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private 'Gravel Pack ❑ Tracy Type of Casing _5C 1-1-y0 Pi(C Specifications I'1 Public (7 Other n Delta Depth of Grout Seal Type of Grout r¢ eA-r SIL4r 1 I Irrigation X Approx. Depth I I Eastern Surface Seal Installed by 4A�A V1 7y Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ 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 O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Propeny.Line DISPOSAL PONDS ❑ G 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 Home owner or licensed agent's signature certifies the following,"1 certify 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 sub-contracting 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 lows of California." The applic ust to or/alll req)ifired inspections. Complete drawing on verse side. Signed I r%�v Title: � 6�e� Date: FOR DEPARTMENT USE ONLY Q Application Accepted by Date / Z Area Pit or Grout Inspection by Oat e Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ( Environmental Health Permit/Services U 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 _ INFO EEE AMOUNT DUE EEj AMOUNT REMITTED CK it CASH RECEIVED BY DATE PERMIT'NO. ' N 1J-20