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SAN 1.eQUIN COUNTY PUBLIC HEALTH '.0"1VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby ande.to San Joaquin County for a permit to construct and/or install the work herein described. This application in 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 Address ✓r� +C- 14 e City Lot Size/Acreage - Owner's Name Ad!drre�ss /� '/ ^ Phone Contractor�iJ iiL �L� Address /�r 0, //�C� „ Ae (cense Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR 0 OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pacii7 ❑ Tracy Type of Casing_ Specifications I'I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ W Well Destruction ❑ Well Diameter Sealing Material i Depth r�rAAl Depth Filler Material i Depth L) 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITIONavailable within 200 feet.) DESTRUCTION I I (No septic system permitted if public sewer is +U ly I/ . ....... Installation will serve: Residence L Commercial_ Other Number of living units: Number of bedrooms,_ Character of will to a depth of 3 fast: Water table depth �l SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line T- LEACHING LINE t9 No. & Length of lines ��- Total length/size- Fr FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS if Depth ,it'T Size _ Number v SUMPS Distance to nearest: Well/va Y��'Found F7` 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 fol owing: 'Y certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workmen's compensa- tion lawn of California." The applicant must call for NI re fired ins cions. Complete drawing on reverse side. C. /J Signed K Title: . 4 1 u- Date: ✓' FOR DEPARTMENT USE ONLY Application Accepted by Date q7— Area Pit or Grout Inspection by Date Final Inspection by Data T 2 Additional Comments Applicant - Return all copies to: San Joaquin County.Public Health Services Environmental Health Permit/Services 445 N San Joaquin, O Box 2009, Bike, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED11 CK RECEIVED BY DATE PERMIT NO. INFO w�. �i • EN 13-21 IREV.I IN 51 s� 11q-� 114-"r/ Inge ct7 8 2-Z Z q2-,Z,9p 0 EN 14-b