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APPLICATION FOR PERMIT SAN MAQUIN COUNTY PUBLIC HEALTH SrMVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED capy (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 1s made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County''Public Health Services. J _/ ff. 90Z 9 Job Address (J�lL(1� r " e / / 7 City /_ /fL.L/ , Lot Size/Acreage 7..3 r✓C' esefti�E�+ �L !� al ��if 9saya Owner's ams r Phone -O Contiactor LL"` S AddresII i.Ct X IZ/ - License Nol6�Phone Z TYPE OF WELL/PUMP: NEW WELL T7 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ 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 SPECIRCATI N ❑� Industrial �❑�,, Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casin YYDomastic/Private artaravd Pack ❑ Tracy Type of Casing_ Specifications jr, Public 1-1 Other n Delta Depth of Grout Seal Type of Gfou I I Irrigation _Approx. Dept I I asternc/.a�/aCe Seel Installed by Repair Work Done LJ Type of Pump L!. H.P. / 12— State Work Done S Well Destruction ❑ Well Diameter Sealing Material i Depth OQ Depth Filler Material i 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 210 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units: _ Numbe of bedrooms Character of still to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to neaV Foundation Property Line CCC\\\Y LEACHING LINE ❑ No. 6 Length of lin ,` Total length/size nom. FILTER BED ❑ Distance to near C. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to merest. Well ndation Property Line DISPOSAL PONDS ❑ 1 herby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state levee, and rules and regulations of the San Joaquin County Home owner en agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not empby any 'stip in w mennar as to become w ct to workman's compensation laws of California-." Contractor's hiring or sub-contracting signature certi}ies t fobwnrp: "I rti♦y that in parlor a e of the work for which this permit is issued, I shall employ persons subject to workman's compenH- tion 4 of Cali( rnle." The • ken st or MI mp ate drawing on — sidJe/,'�,f, Sign fs Title: / Data: '.-5 DEPARTMENTFOR USE ONLY ` /- 1 � Application Accepted by � rx d7�1� 1 "Date Area . � Pit or t tat Inspection by �� ` // to C22 Final Inspection by 7" t Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Servlces 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 .LWFEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED By 0 TE PER NO. . EH 3.241REV.heel " ,pp fH re ml /