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SAN JuiN COUNTY PUBLIC HEALTH S VICES IRONMENTAL HEALTH DIVISI c I[ra.-hu✓i5 445 h SAN JOAQUIN, PHONE (209)46420 P 0 BOX 2009, STOC%TON, CA 95201 G - I ,`ktr✓ Et -lip PERMIT E%PIRES 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 vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. f Wo,r 5677 ter (a ply snel l Sf{c I tx 4rd C -t �J SIS Nq,VU � City Sir,-c-p-I.�.i Lot Size/Acreage Job Address �,/I y � Owner's��N�r��a,me Ql,. rA vN Address Phone Las ` OF PiO1r' 1 1'tr� 1 RG+(1G NIJ LG✓G(1JL�. I,b/ Pox On% KX ar01:h/,v1 �jZ41 ��'i Grwld License No. G'� /aOiZ�D Phone 95� Contractor T(A.y Y1C� p Address 9 / TYPE OF WELL/PUMP: NEW WELL E WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Servii1ce Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 11OTHERX CycopMr°-os C begr y,)❑ DISTANCE TO NEAREST: SEPTIC TANK V5 -!o SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION A'ler-Imt AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Na L] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation z' Dia. of Well Casing (-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing s Specifications 11 Public ❑ Other n Delta Depth of Grout Seal I'J �' Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by �V Repair Work Done ❑ Type of Pump ^- H.P. State Work Done _ Well Destruction ❑ Well Diameter hfr^" Sealing Material 4 Depth V� Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public tower is available within 200 feet.) \(� Installation will serve: Residence_ Commercial_ Other 13 �1 Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 1J PKG. TREATMENT PLT. ❑ Method o1 Disposal Distance to nearest: Well Foundation Property Line f+ LEACHING LINE ❑ No. & Length of linea Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sae Number �w SUMPS - LI Distance to nearest: Wall Foundation Property Line DISPOSAL PONDS ❑ 1 hereby comity 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 permit is issued. I shall not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractors hiring or sub-contracting 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,91 at call ler all required inspections. Complete drawing on reverse side. Signed kA� � Title: �'Cw ^e \ Date: - Application Accepted by L FOR DEPARTMENT USE ONLY �. � Date Area Cfg2.�UQGtj ,r'� Pit or Grout Inspection by Date , Final Inspection by Date 71241i Additional Comments: �.�d�Lyl � � Applicant - RetY n al copies to: San Joaquin4Q.unty Public Health Services Environmental Health Permit/Services 'tom 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IE9 UNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EN UQtREV.irnli e� Q 9�� ? l> 5� 60360; EH 14-M