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SAN( JAQUIN COUNTY PUBLIC HEALTH` .RVICES I - ENVIRONMENTAL HEALTH DIVISION 5 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or Install the work herein described. This application Is grade in complisi with Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. py.p XJob Address I' �rf« �(3a Aa City fit_ Lot Size/Acreage )(10wnar't Nana a 8/i eSC/Aa i Address S-7`i}'S1 {AUC Phone .4 6 Z - 7 C 9 9 "XCpnOau � atnONJT x�� i 4'8 �yi' 9 Address /• Qok ?7 S�& License No. 9Phone -90_ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION C. Out of Service Well C. PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L1, - DISTANCE TO NEAREST: SEPTIC TANK' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIO4 AGRICULTURE WELL OTHER WELL A. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ',y ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. Of Well Excavation Dia..of Well Casing ❑ Domestic/Private ❑ Gravel Pachl ❑ Tracy Type oYCasing'- Specifications I'I Public ❑ Other I ❑ Delta Depth of Grout Seal - Type of-drout I I Irrigation _-Approx. Depth I I Eastern Surface Sae] Installed by I Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material a Depth Depth 'Tiller Mefertal-&'Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION 1 1 DESTRUCTION (No seplic system permitted if pubticsewef is available within 200 faeLl ' Installation will serve, Residence A Commercial_ Other r j Number of living units: _ Number of bedroome'� j >... / Character of soil to a depth of 3 leer: "Water table depth_ SEPTIC TANK ❑ Type/M f a tit -'No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal t - Distanc to,neer st. IVIIII un a to Property Line LEACHING LINE ❑ No. A Len lh o b as. pI' �frCETG Total length/size FILTER BED ❑ Distance t bein"v e e F .h—g 1l p ed Property Line ' `- jr-n nm 'al Na�Mh nPjial9n SEEPAGE PITS 11 Depth { Sixe Number SUMPS - Ll Distance to nearest: Well Foundation Property Line /{ DISPOSAL PONDS ❑ '1 ` r I hereby certify that I 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 whichthis p$rmit is issybe, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's niFing or sub-contecling signature certifies the following: "1 cenify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-, tion Iowa of California." The applicant njust call for all required inspections. Complete drawing on reverse Side. .1 ' `� T _ Signed X � �S r'" Title: S�pea" �x1Or Date: IG 9z FOR DEPARTMENT USE ONLY Application Accepted by C v,`Saa�---t� l- Date Area ' O 1 Pit or Grout Inspection by Date Final Inspection.,by 'Date Additional Comments: I 1 Applicant ant - Return all copies to: San Joaquin County Public Health Services I environmental Health permit/Services IIM 445 N San Joaquin, P O Box 2009, Si GA 95201 fEE AMOUNT DUE I AMOUNT REMITTED CASH RECEIVED BV DATE PERMIT'NO. EH 4za I \/