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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 made to San Joaquin County for a permit to construct and/or install the work herein described. This application Is made in compllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �3fS7� `t�� c2�� (� _ City +:C.ii-�,1+� Lot Size/Acreage 0 Owner's Name C-9 Pet ll srs,t..h^K Address fN-e� 11 Phone r- Contracts ate\ 1 Address `�sri z ♦ ,AR License No. .3��DZZ Phone -3 '33 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Fl PROP. LINE _ FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public Ll Other 1 fl Delta Depth of Grout Seal Type of Grout I Irrigation _ q f Pum Depjh I I Eastern Surface Seal Insulted by Repair Work Done ❑ Type of Pump )--------K,P. Stats Work Oona_ Well Destruction ❑ Well Diameter 'Sealing Material a Depth Depth Fillei.Meterial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I Wo septic system permitted if public sewer is available within 200 feet.) Installation will earl Residence Commercial_ Other Number of living units: —Jf — Number of bedroom} Character of soil to a depth of 3 fast: C\ '\ Water table depth r SEPTIC TANK 0• Type/Mfg Ce,.Y• fvy Cf' Cs ci L�nrr De t1'-1 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation l Property line 1 Caf) LEACHING LINE 6- No. g Length of lines �sTotal length/size / ' r FILTER BED ❑ Distance to nearest: Well t� i Foundation III Property Lina `70 r SEEPAGE PITS M Depth �`l` - ----$ize - ,G, Number SUMPS LI Distance to marasC Well :ACV • Foundation Property Line DISPOSAL PONDS O 1 hereby certify that I have prepared this application and that the work will be done in accordance wiIth 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 cenify that in the performance of the rork 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 Californiar 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 shalli%ploy persons subject to workman's compensa- tion laws of California." The applicant must o 'all required}n C' ns. Complete drawing on reverse side. Signed X �1 �/I)� Title: s<Y ))ACK Date: /a — FOR.DEPARTMENT USE ONLY Application Accepted by D Z \ �y��1^/ ,c� Date '9� Area or Grout Inspection by �� a-6 to �LFins p ,�// pection by �-- / `, r r/iDet T Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO M CK RECEIVED BY GATE PERM17 N0. • EH tY3�(REV.1/"5) to EH t4-a] 4