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APPLICATION FOR PERPIf r SAN JOAQUIN COUNTY PUBLIC HEALTH t�lCSi.S. 1 1I)v� 445 N�SANOJO QUIN, PHONEHDI VI (209)�QQ9 Agn L�3 P O BOX 2009, STOC%TON, CA .rte PERMIT EXPIRES1 YE FROM D TOaVEP � (Complete in Triplicate Application is hereby made to Ban Joaquin County for a permit to construct and/or Install the work herein described. This application 1s made In cootpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. _ xo Acyer Job Address .S'�.5-0 1//aN f)LL ny RdCity S1Z; �J'r c- Ct/ Lot Size/Acreage Owner's Name 171:44- ��/L� If%� Address -$�iZS� ✓f1/ol 1/G<C',s- Phone Contractor �'��' "� SOH Address �nl'i( �L'i<" Gr�Y �r�'• License No. yYr Sr Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ _ PUMP INSTALLATION ❑ - SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L� 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 Caning Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public Cl Other n Della Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by (F Repair Work Done LJ Type of Pump H.P. State Work Done _ j Well Destruction Material b Depth n ❑ Wall Diameter f{ Depth Tiller Material b Depth C TYPE OF SEPTIC WORK: NEW INSTALLATIONA REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 fast.) Installation will serve: Residence -L— Commercial_ Other Number of living units: / Number of bedrooms 3 Character of son to a depth of 3 fast: GG Water table depth SEPTIC TANK @ Type/Mfg NnfLr '01rX Capacity hfr)b0 No. Compartments h• _ PKG. TREATMENT PLT. ❑ Method of Disposal t� Distance to nearest: Well PW ` Foundation /0 Property Line tan 'n LEACHING LINE No. b Length of linea A - $fI Total length/size / FILTER SED ❑ Distance to nearest: Well Foundation `f�� Property Line SEEPAGE PITS f/1 Depth Size 36 ZWV- Number -At' 3 _ SUMPS LI Distance to nwresD Well 00• Foundation /Xy Property Line 5c" r DISPOSAL PONDS O 1 hereby certify that f 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 San Joaquin County Home owner or licensed agent's signature certifies the following: "I comity that in the perlormance of the work for which this permit is issued, 1 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 prtifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws o/ California." The applicant y^^9 pt call for MI required inspections. Complete drawing on reverse side. Speed XML \� Title: Date: FOR DEPARTMENT USE ONLY _ Z14, A ication Accepted by - Dat s A a If Pit r GyLE+t Inspection by / Date Z' r Fines Inspection by '� l2 Date 2 c Add ar'y�fj��`omrtrnts: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, Box 2009, Stkn, CA 95201 FEE ZI I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED aY DATE PER/\MIT-NO. EN i}24 IREv.ren al —EN 1431