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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)4 420 P O BOX 2009, STOC%TON, CA 9 PERMIT E%PIRES 1 YEAR FROM DATE ]Ml, y37v (Complete in Triplicate) -'1 # - Application is hereby made to San Joaquin County for a permit to construct and/or inete a vo h bed. Thi application 1s made in compliance vlth San Joaquin Count Ordinance No. 549 and 18-W '1'TY'w' t e Ne latlons of San Joaquin County Public Health Services. �� {Il�� l._ 1� '\ J Job Address `-7 0 11 WM L� City I a rm,'3 n' ILot Size/Acreage '3V 0 T I/c T Owner's Name So �i� &a f��re� t Address 5435 6an IQV ICotf / �n��I�� bs Contractor MA r 1 (k Address /\ L' O () ll�t� License No. 3t0 V 'OSI Phone b3q TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION %I SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ g0( DISPOSAL FLO.� PROP. LINE I2 01 3 f ! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -LO0 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j S/ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing (� 'Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ 5-pSpecifications 1'I Public I1 Other 11 Delta Depth of Grout Seal 1 O1), Type of Grout-&R I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump L4 61 H.P. 11/7 State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material A 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.) 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Distance to nearest: Well Foundation Property Line a"H 7 _ LEACHING LINE ❑ No. d Length of lines Total length/size nor 1 w FILTER BED ❑ Distance to nearest: Well Foundation Property LinS _ Y p(IR1IAl tt ICuUNi 3-zR, r r— SEEPAGE PITS 11 Depth Size Number EN'IEDNVI , r 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 laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "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 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 laws of California." The applicanrl^/;�'stt call for all required,ins ions.. Con plate owing on reverse side. -�J Signed X7,7c� ' n yiC�7"-4 Title: / T fiyi Date: � FOR DEPARTMENT U ONLY - Application Accepted by �`�- Date Z res n Pit or Grout Inspection by Date Final Inspection by 1 � Date 7 3 Additional Comments Applicant - Return all copies to: San Joaquin County Public Health Services Env 445SNOSanntal Joaquin,Health P 0 Box 2009, ces Stkn, CA 95201 --f-11A FEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY IDATE t LIT((('1N0. EH a M