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APPLICATION -A SAN Jt)AQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ' 445 N SAN JOAQUIN , PHONE ( 209 ) 468 - 3420 KT � � - `"w - Z P O BOX 2009 , STOC%TON , CA 95201 A ) p PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ( Complete in Triplicate ) " 7,s �f . o S Application is hereby made to San Joaquin County for a permit to construct and/ or install the work herein described . This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San 'l Joaquin County Public Health Services . - - rTP. t .-, q(Larlc - - Job Address City Lot Size/Acreage _I 7 ZZ 1= . ��C Il r10 �, '-+t�-_ ,1 � Phone - Owner's Name OU ; " 1 t- - �Y. •. r+!ll111 Address `j't' ✓ — Contractor 'Z NAddress ` • T` i ' - `moi - _ _ ' License No. Phone 71 TYPE OF WELL/ PUMP : NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO , PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS / SUMPS - _I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -�'�' - �'- "• -"»-r �' . L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation k g ia — II Ca Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Spacitications_7-1�tc,` i •1 Public I.1 Other nDelta Depth of Grout Seal Typ"LXG out `- ) 11 Irrigation _ Approx . Depth I I Eastern Surface Seal Installed by T"' tiD 3"" 1❑'N' I Repair Work Done ❑ -:. Type of Pump H . P. — State Work Done _ f_l I•�--L' '— ">�� _ Sealing Material Depth Well Destruction ❑ Well Diameter i Filler Material Depth Depth TYPE OF SEPTIC WORK : NEW INSTALLATION I I REPAIR / ADDITION I I DESTRUCTION I 1 Mo septic system permdublic sewer is _ available within 200 feet) Installation will serve: Residence _ Commercial _ Other ' — Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r 1 SEPTIC TANK - ❑ Type/Mfg Capacity. No. Compartments _ I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size - — � FILTER BED . ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number -- SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 San Joaquin County m ' Home owner or licensed agent's signature cenifies the following: 01 certify that in the performance of the work for which this pbrmit 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 snub-contracting signature —i 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 must call for all required inspections. Complete drawing on reverse side. Signed Title: Date: � � 1r'1-T. FOR DEPARTMENT USE ONLY / Application Accepted by Date > e Area Pit or Grout Inspection by Date Final Inspection by Date _ Additional Comments: Applicant - Return all copies to : San Joaquin County Public Health Services Environmental Health Permit/Services 1 445 N San Joaquin , P O Box 2009 , Stkn , CA 95201 C) a FEE AMOUNT DUE AMOUNT REMITTED N RECEIVED BY DATEPERMIT' NO. - ' INFyO/j _1 EH 12-241BEV. 1 ; x51 / , I � � /�l ra • r l' /� ��/ 1/ 7 : rl , (. / : /�� / - 3Q9 EH 14.76 T C