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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEAL H(VICES ENVIRONMENTAL HEALTH DIV S T� 445 N SAN JOAQUIN, PHONE (20 )4420 P O BOX 2009, STOC%TON, C FQ$$(�? PERMIT EXPIRES 1 YEAR FROM D I 'i'SS (Complete in Triplica eINV # -7 -7 -719 Application is hereby made to San Joaquin County for a permit to construct an application is 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 f� • C ( C d✓✓L C / City C A, Lot Size/Acreage Owner's Name `-+`-- 1�; /-��.r/�/A�`� Address C2 J�dT G n.f AL Phone Contractor (0"v A/'4P-A- Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LI Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public I l Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. __ 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 DESTRUCTIO (No 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 fast: Water table depth SEPTIC TANK ❑ Type/Mfg C Capacity lJtl!�a No. Compartments PKG. TREATMENT PLT.❑ //'' ^ �11 Method of D' sal Distance to nearest: Well((",". Foundation-PO 7Property Line. G LEACHING LINE ❑ No. 6 Length of lines Total length/siz MENT FILTER BED ❑ Distance to nearest: Well Foundation PropenWED SEEPAGE PITS 11 Depth Size Number ��ssMilt --��++ SUMPS LI Distance to nearest: Well Foundation Props(�tt�y(�� NTY DISPOSAL PONDS ❑ SP1NyM N4 CES lillsiou I hereby cenify that I have prepared this application and that the work will be done in accordance vyi N1 finances, state laws, and rules and regulations of the San Joaquin County C 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 subcontracting 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 compensr tion laws of California." The applic Ntust call for all ui ad inspections. Complete drawing on reverse side. , Signed Title: Date: - FOR DEPARTMENT USE ONLY �z Application Accepted by - Date Area �.> Pit or Grout Inspection by Date Final Inspection by Date 21_/7 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services Itp_fes\ 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 \']t/ FEE AMOUNT DUEAMOUNT REASHMITTED RECEIVED BY DATE INFO PERMIT NO. xt0• Em IN Ia-at O�