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A447-c APPLICATION 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 do �TIt�C`r A pp(tE 5 S (Complete in Triplicate) �oi� f3os r•J�s Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is rade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San ; nh2 1,sy Nbo�-thHealth Services. S.eitwrea�o fLok� oa prRT Romeo o� .a So'XSu Sf,,GEro dk 7 Job Address cocyrern 04 4, rs Sou�q it; E1roer mice- U4 city 5 A41 Les Lot Size/Acreage PGt g C-asscippd r S w Oner's Name Y 6u s i Hess 1! )if+ Address Phone T'es+i mar i Aef Contractt'� AddrFSs S0 License No.�Phone TYPE OF W£"4RVMP-- NEW WELL O WELL REPLACEMENT FI DESTRUCTION O Out of Service Well O 41 (�,Opi-I0Ees PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER 'ti( Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE 10TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LLf� ❑ Industrial O Open Bottom ❑ Manteca Dia of Well Excavation Dia. of Well Casing r] Domestic/Private O Gravel Pack ❑ Tracy Type of Casing__ Specifications I"I Public (7 Other ❑ Dena Depth of Grout Seal Type of Grout 11 Irrigation _Approx. Depth I 1 Eastern Surface Sedl Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC VyOK. NEW INSTALLATION i 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer p Yn�l(/e/ available within 200 feet.) Installation will rve: Residence_ Commercial_ Other Number of kvuV units: Number of bedrooms Character of soft to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE #4 CI No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS A)(4 11 Depth Size Number SUMPS I LI Distance to nearsst: Well Foundation Property Line DISPOSAL PONOS O 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 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this perms is issued, I shah not employ any person in such manner as to become subject to workmen's compensation taws of California." Contractor's hiring or sub-contracting signature certifies this following: -I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compsnsa tion laws of California." The applicant.1_= tions. Co ete drawing on reverse side. (� Signed u or all requir v`'�7 Title: J Date: / /d - GccR,J 0 FOR DEPARTMENT USE ONLY Z,/ , Application Accepted by Date �J / 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 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED R RECEIVED By DATE PERMIT�NO. /J Page 13A Eli 4-2a EM 4-30 Em rr.m) VI `�'2 JL7.J�� 1 V