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—� APPLICATION - I SAN JOUIN COUNTY. PUBLIC HEALTH SERPICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 D P 0 BOX 2009, STOC$TON, CA 95201 PERMIT EXPIRES YEAR''•FROM DATE ISSUED APR 1893 (Complete in Triplicate) ENVIRONMENTAL HEALTH Ayp lication is hereby,tiiade to San Joaquin County for a permit to construct and/or install the work h%9M1�[eM This application is made ir0ccuplianee vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations o San it Joaquin County Public Health Services. Job Address �• � GitY "'��'1 Lot Size/Acreage �� C2 � I /' /200'fM I7rr _ Sf r t 7z• 3l0$ i G Co. aS1 Address /7i4ts- h �cxas Phone Owner's Name C7 I,4 ,6 34 Phon(707 -374 o `�{ Contractor W, U1orc,�w� ��I�� dQress PQ.43n iX 33,E b Vr} License No. 581 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ f PUMP INSTAL SYSTEM SYSTEM REPAIR Ell+fon OTHER ❑ itoring Well >( Z DISTANCE TO NEAREST;: ;SEPTIC TANK �L, SEWER LINES �� DISPOSAL FLD. N PROP. LINE FOUNDATION L�Z.�' AGRICULTURE WELL "N/' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f C1`Industrial ❑ Open Bottom ❑ Manteca Elia. of Well Excavation Dia. of Well Casing' IA 4e, D DomesuclPrivate Ll Gravel Pack ❑ Tracy Type of Casing_?yC jcA0.4k ZSpecifications Ci Public _ Other t1 Delta Depth'of Graut Seal '3 C1 Typa o1 Grout T %J J I I Irrigation Sri-(2t! Approx. Depth I I Eastern Surface Seai Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material'& Depth E epth Filler Xaterial i Depth ' i TYPE OF SEPTIC WORK: . NEW INSTALLATION i I REPAIR/ADOITION I I DESTRUCTION I I (No septic system permitted it public sower is available within 200 feet.l Installation will serve: Residence— Commercial Other (\J Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 10 Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT.-❑ Method of Disposal Distance to nearest: Well Foundation' Property Line LEACHING LINE C1 No. b Length of lines Total length/size FILTER BED 0 Distance to nearest: Wall Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line - DISPOSAL PONDS .❑ - 1 hereby certify that I have prepired 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 a ant's nature certifies the following. I certifythat in the performance of the work for which this rmit'is issued, I shall not g, �9 g. ,. pe pe employ any person in such:manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature . kA certifies the following:"I csrtify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must all for,: 1 required inspections. Complete drawing on reverse side. {A !A1 r, Signed Title:: S f7� �re�"�a�i U7 Date: __ �T�"l - -3 • FOR DEPARTMENT USE ONLY L7/ Application Accepted by Date J�O Area Pit or Grout Inspection by,. Dater/ Final Inspection by Date 6/,3Additional Comments: N � � ter+ 061 �I � �• fie- c 7* •02 Applicant - Return all copies to: San Joaquin County Public Health Services f Environmental Health Permit/Services ' I 445 N San Joaquin, P O Box 2009, Stkn, CA 95202 1 AMOUNT DLIE AMOUNT REMITTEO �K AELEiVED By OATS Pt RMt7 O. FEE , INFO y/��/J� g.CAS�HQ