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APPLICATION SAN JOAQUIN COUNTY PUBLIC HEAL SR G&S— 000u �— I ENVIRONMENTAL HEALTH DIVI '�ygn� u y3.7y 445 N SAN JOAQUIN, PHONE (209 7Cl +ID P O BOX 2009, STOC%TON , CASrI'1l�?tL# f 111- fG PERMIT EXPIRES 1 YEAR FROM DA E ED -LN r (Complete in Triplicat ) /I / Application to hereby mede,to San Joaquin County for a permit to construct and/or install the work herein described. This application in made in coelpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Counts Health 3ervicfs. y ladL Job Address � /`� \,(ny(' I}"Tl w rr � City F/-� ft Ke,, �1 Fr h^A�CS IM _n �Idrd s go 2 " N , G I U F1 1 F Y l , Phone 8 Owner's Name �--� I a/tip 1N ' I d Contractor Mr-✓yld.t �-_Address �� License No. Pnone TYPE Of WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION Ll Cut of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1MonitorsNell !i 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER'LINES DISPOSAL FLD. PROP. LINE �z..r FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS IN�NDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIF1CATiONSr C 7� 1 b ❑ Industrial a ❑ Open Bottom ^❑ Manteca Die. of-Well Eacavaiodn. -'6 'Dia. of Well Casing " fT y...Specificanons 1 1 Q".([g` Domestic ❑ Gravel Peck ❑ Tracy Type of Casing_ I 1"Public ti t rlf" 4 1-1 Other (l Dena �s`t Depth of Grow Seal 1 Type of Grout. f I I nrigation i �� I —Approx. Depth Eastern Y / udace Saul installed by 0'A. f11 -Repair Work Dore• U Type of Pump� H.P. ---- State Work,Done _ V NI OsatruGion rl ❑ Well Diameter Sealing Materinl a Depth U (�- PilletMaterial a Depth Depth .. _ t.. TYPE OF SEPTICWORK, NEW,INSTALLATION-I 1 -REPAiR/ADDITION I{� DES 7R UC TION I L(No septic system permitted if public role yet is C „ r available within 200 test.) npa�delion'wia�sarSl:JReald�fe=�Corrlm'erual I Other Number,of-livngW' ,Uo: _ Number of bedrooms f •,;•. ( 1 `f. _ Character of soil fr�ooy.st as depth of 3 tool: 'r f i Water table depth r� 5EPTIC TANK.ry�. 'r ❑ Type/Mfg j i `Capacity No. Compartments PKG. TREATMENT^ T.•CI Method of Disposal Distance tonearest —;Foundation 1 Property Line i tet.-- Total len th/size �CEALHiNGTfNE ❑-""No:8 Lengtn of 1 9 � , ' ;FIL YER BED ClDistance to nearest: Well Foundation Property line 4-1" r� .SEEPAGE PITS 11 Depth Size Number `SUMPS LI Distance to nearest. Well Foundation__ Property Line DISPOSAL PONDS ❑ n hereby candy that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances..ststa laws, and "rules and regulations of the San Joaquin County .` ' Home owner of ncenxd agent's signature certifies the following: "I certify that in the performance of the work for which this permiris issued, I shall nm � employ any Person in sato manner as to become wbpm to workman's compensation laws W California." Contractor's hiring or sub-contracting mgnato re certifies the following: 'I cemly that in the Performance of the work for which this permit is issued.I shall employ Persons subject to workman's compenea tion laws of Califorina.- The applicant must call for all required inspection Complete drawing on reverse aide. m Date: 15;gned X� `��•�— �L___ t — i i I FOR DEPARTMENT USE ONLY 1 Date Area o2� Appliclllon Accepted by Pit or Grout Inspection by to Final Inspection by Dais F3 Additional Cortolfroo Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkni CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED By DATE PERMIT NO. NF I EH 13-M IREV. � I QO �03� \ J•� U EH 14126