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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 I (Complete in Triplicate) Application In hereby sade,to San Joaquin County for a Permit to construct and/or install the work herein described. This application to made In Compliance frith Han Joaquin County Ordinmce No. 549 and 1862 and the Rules and Regulations of Ban Joaquin County QPublic Health Hervieea. Job Address //i{� •�('-,� c) " yam+. ' C,ly � Lot Base/Acreage Owners Namet^-""''^""'"' � — Address O`✓ �, Phone ConBact ' ' IAddress r✓• License No. 2VZZ6 Phone 6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Servicer Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 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 0 Industrial ❑ Open Bottom ❑ Manteca Die. of Wall Excavation Dia. of Well Casing P Domestic/Private ❑ Gravel PacIA7 0 Tracy Type of Casing_ Specifications I•I Public ❑ Other n Delta Depth of Grout Seal Type of;Grout I I Ivigation _Approx. Depth 1 I Eastern Surface Saul Installed by Repair Work Done ❑ Type of Pump< H.P. - State Work Done_ Well Destruction ❑ Well Diameter, Sealing Material i Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1REPAIR% available within 200 fast.)ODITION DESTRUCTION 1 I (No septic system permitted it public sower is Installation will wive: Residence Commercial_ Other / Number of living units: -62- Number of yp(J7Doms Character of wa to a depth of 3 lest: • ^�1 - 0`�frn.va Water table depth SEPTIC TANK 0Type/Mfg Capacity No. Compantheids PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to nearest: Well �' • ,Foundation Property Lim N •+, LEACHING LINE Cl No. 6 Longih of linea ` �1-�' �� ( -'F T?tat Iength/size 1-0/ e 'FILTER BED :Distance to nearest: Well,�(X,[,�{Foundation n t Property Line � y y-°HEEPAGE PITS 1 I 'Depth.- - .ie - 1 - Number SUMPS LI Distance to nearest: Well ` Founii ition Property Lim u .._-DISPOSAI PONDS`, b",`.-",�'r�'"�-•��."`vl,�'.....-�,.;�=.,.,-;y-. _. .�:_ '-• _ _ _. - 1 hereby certify them I have prepared-this-application and that the work will be donein accordance with San Joaquin county,ordinances, state laws, and rules and regulations dl the Sen Joaquin County Home owner dr licensed agent's signature:certifies;the following: "I certify.thai try the perfStmance of the work for which this permit is issued, I shall not employ any person in such manner as to bscomesu6ject to-workman's compensation-laws.of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for whiaii this permit is issued, I shall employ persons subject to workman's compensa tion laws of California." The eppliECepted r quired inspections. Complete drawing on reverse sideiY�Signed X Tills: � Data:n2 9Z FOR DEPARTMENT USE ONLY Applicatio '`y`• 'Oita Area ..-, q Pit or Grout Inspection by Data Fidafinspecdoti by Cly '� Date z-3-9� Additlonsl Comments: - _ _ i Applicant - Return all copies to: San Joaquin County Public Health services Environmental Health Permit/Services + ^F 445 N Sap Joaquin, P O Box 2001#, 5tXn,'dACii FEE AMOUNT DUE AMOUNT'AEMITTED CK a, RECEIVED by D TE PERMIT NO. NFO /I /J < IN Iy.11(ON �n 51 fM IAM