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APPLICATION FOR PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 (Complete in Triplicate) Application in hereby made to San Joaquin County for a permit to construct and/or install the vork herein described_ This application is made in compliance vith San Joaquin County Ordinaries and 1862 and the Rules and Regulations or San A/Joaquin county Public Health Services. /Uon Address City (--/P-111G Lot Size/Acreage XOwner's Nam-/-Y� �lAC r/ P / Address ( �6g ^ e r� Phone / 1 v / Conlraclor �llrn��/Q Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service bell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring bell L3 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 Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications - 11 Public EI Other Ll Delta Depth of Grout Seal Type of Grout_— \ I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by C Repair Work Done U Type of Pump H.P. State Work Done _ C Well Destruction ❑ Well Diameter Sealing Material a Depth Depth Filler Material A Depth �T YPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence 4 Commercial_ Other r 7 Number of living units: _ Number ot tpdrooms /Lp Character of WA to a depth of 3 feet: ,Hyq+- /4/✓ Water table depth .� SEPTIC TANK � Type/Mfg - Co"'c-"f--10-C Capacity No. Compartments 2 PKG. TREATMENT PLT.❑ 1 Method of Disposal Distance to nearest: Well SOD Foundation 30 Property Line LEACHING LINE No. B Length of lines `4 X q Total length/size z-V IIvYY FILTER BED ❑ Distance to nearest: Well 00 Foundation O Property Line/ �,t _ I i If !f _ SEEPAGE PITS It✓ pth �� S Size Number J � SUMPS Distance to nearest: Well { Sp . .,�ounaLieR, -qo L�7 Property Line S DISPOSAL PONDS ❑ - y ?�' C- I hereby certify that 1 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 Sen 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in IM performance of the work for which this permit is issued, I shall employ persons subject to workman's compenu- tion laws of California." T The applicant t call for MI mad ins p ctions. Complete drawing on rev side. V /1Spned X' _ i1'r r l Title: �R-+t---e Date: 2-12, / / I FOR DEPARTMENT USE ONLY O� Ap iu on Accepted by ttu,-e1+7�e Date 1^ Z Area D 1 Pit r Gr �pjiction by Date Final Inspection byA111Den L� dditional Comitants: 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 MOUNT REMITTED SH RECEIVED BY DATE PERMIT NO. ✓ INFO �. EN t124 IREV.v s 51 m / .� l EH 430 I�/ t 77��