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APPLICATION FOR PE I SANyJOAQUIN COUNTY PUBLIC HE ;ERV T(J-- ENVIRONMENTAL HEALTH D 001+ 445 N SAN JOAQUIN, PHONE ( 6$-342 P O BOX 2009, STOC%TON, F�952�1 r PERMIT EXPIRES 1 YEAR FROM E/ I SU `7 0 � (Complete in Tripli a Application Is hereby made to Ban Joaquin County for a permit to construct and/or install the vork herein described. This Application In side 1n compliance vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. p y 9S M , (� �/ �y..�' Job Address 1 City Lot Wt Size/Acreage Owner's Name P Address ' Phone '3(0q- 7 -7 JZDZ 6 Phone. � License No. SOSContracl y67J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 ❑ Industrial ❑ Open Bonom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ,Specifications I') Public (1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Filler Material i Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAI ADDITION DESTRUCTION I I (No septic system permitted if public sews, is available within 200 leet.l h Installation will serve: Residence V Commercial_ Or or �1 Number of living units: _J_ Number of Grooms 1 Character of we to a depth of 3 feet: _Water table depth SEPTIC TANK ❑ Type/Mfg r / Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ Method of Disposal (y� Distance to nearest. Well Foundation Property Lim I" LEACHING LINE �F(_No. 8 Length of lines Total length/size U a / t FILTER BED ❑ Distance to nearest: Well� Foundation /O t Property Lina SEEPAGE PITS Pt Depth �Jumbar f SUMPS Distance to nearest: Well 10H•t- Foundation lc� 1- Property Lina 4- DISPOSAL PONDS ❑ 1 hereby certify that I he" 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 cenifies 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 workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant�st cell,1fo�ri uir d incpephons. Complete drawing on reverse side �� Iy1- Lj Signed K 1-IZ1�A Q Title: �J, Date: 1 I 1 llllll(j��/Jll DEPARTMENT USE ONLY Application Accepted by Date f Area / Pit or Grout Inspection by `~ Date Final Inspection In <— Date O / Additional Comments �- yM ✓ 6 p r !S LZO, Applicant - Return all copies to: San Joaquin County Public Health Services 6ti` 0//3/43 Environmental Health Perm.t/Servs see 445 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT NO. INFO T D ,t-,i `CoASH X72 ) ,r7 �N,124 l.Ev.ir•sl 11 �• VV / �/V / //�.� /./L� ♦�..,, / G / �:� / IN 41e