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/ SAN JO_AQUIN COUNTY PUBL_IO_HEAL-TH—SE VRRW_ ENVIRONMENTAL'H$ALTH DIVISION 445 N SAN JOAQUIN., PHONE (209)468-3442)! # P O BOX 2009, STOC%TON, CA 95211 PERMIT EXPIRES 1 YEAR FROM'DATE I SUE6 l (Complete in Triplicate) I .':I f' Oo Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein escr e s application 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.. Job Addresst Size/Acreage Owner's Nam �YIJAt Address =�� Phone Contrac Address- 9 Qr License No. _Phone ::Z TYPE OF WELL MP: NEW WELL O WELL•PEIJl ACEM NT ❑ DESTRUCTION ❑ Out of Service Well ❑ / - / Monitoring Well J PUMP INSTALLATION'S --1 SYSTEM REPAIR-W!, OTHER O L7. DISTANCE TO NEAREST: SEPTIC TANK t.�,SEWER LINES DISPOSAL FLO. PROP. LINE tFOUNDATION ,AGRICULTURE WELLY' OTHER WELL PITS/SUMPS _ INTENDED USE .` TYPE OF WELL PROBLEM AREA —CONSTRUCTION SPECIFICATIONS z QIndu ial ' O Open Bottom O Manteca 16ia.,of,We)I Excavation' Dia. of Well Casing \ omestie/Privatel I' 0 Gravel Pack ❑ Tracy Type o(Casing_ Specifications 1 I"I Public Il Other 'n-Dalta----` Depth of Grout Seal Type of Grout I I Irrigation 111 I _ApproK. Dept l 1 Eastern Surface Seal Installed by Repair Work Done IO I Type of Pump (:' H.P. State N! rc one Well Destruction O I Well Diameter Sealing Material a Depth Depth �-� Filler Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I (,...REPAIR/ADDITION I I DESTRUCTION I)�INo septic system permiitdh it public sewer is r available within 200 feet.) Installation will some: Residence_ Commercial_ Other Number of living unite: _ Number of bedrooms f Character of will to a depth of 3 feet: Water table depth SEPTIC TANK. , , • ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT:❑ Method of Disposal - v Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED .L 'r❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS rl 1`Dapth _ Size Number SUMPS 1LI—•Distanote to nearest:- —^Well ._Foundation Property Line ,, __D.ISPOSAL.PONDS! ❑ 1 hereby certify that I have prepared this app&cation'and that the work will'ba-tlone in-acwfdance with Sen-Josquin.tounty ordinances, state laws_,,.and_ y rules and regulationsofthe San Joaquin County Home owner or licensed agent's signature certifies the fohowing: "I 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 subcontracting signature certifies the following:"I cenify 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 T The applicant m CelLfbr all equir spectlo s. Complete drawing on rgQrse al . Signed Title: I'7i _—_ Date: F DEPARTMENT USE ONLY Application Accepted by Date t, Area Pit or Grout Inspection by Date Final Inspection by�� Date .,Additional Comments: `''G "� ^� ...� g� 0�� Applicant - Return all copies to: San Joaquin County Public Health Services O I ,!l to Environmental Health Permit/Services r 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 L r t FEEAMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT NO. NFO • EHt1.241REV.�rasi �/ I S r Q� EH;4 /