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I APPLit 'ATION _ SAN JOAQUIN COUNTY Pit-ILIC HEAFFAU-W � ENVIRONMENTAL WALTH DI � 445 N SAN JOAQUIN, FF:rONE (20 P O BOX 2009, STW,'-KTON, C PERMIT EXPIRES 1 YEAR FROM D (Complete in T: •iplica e V It Application is hereby made to San Joaquin County for a permit to c� iatruct 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 Sari Joaquin County Public Health Services. r r Job Address _ ��' z 'tirl� �� ----- C'ty +'L'�� '� Lot Size/Acreage /Z�,, Owner's Name �~ �—rC� Address Phone [�G i; y'� <A Contractor �``�Y��L�_ _ Address ._��rz�/'� License No. Phone 1 "'� TYPE OF WELL/PUMP: NEW WELL n WELL REPLACEMENT P DESTRUCTION Out of Service Well 0 PUMP INSTALLATION 0 SYSTEM REPAIR Ll OTHER 0 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 (1 Industrial 0 Open Bottom Ll Manteca Dia of Well Excavation Dia. of Well Casing f I Domestic/Private Cl Gravel Pack 1.1 Tracy Type of Casing_ Specifications I•I Public I l Other 1 1 Delta Depth of Grout Seal _ Type of Grout I I Imitation ____ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L) Type of Pump H.P. — State Work Done _ Yi Wolf Destruction 0 Well Diameter Sealing Material & Depth Depth _ Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ix REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is V) available within 200 feet.) Installation will serve: Residence )(_ Commercial _ Other l� Number of living units: Number of bedrooms _ 3 _ ♦ I Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK 10 Type/Mfg %– cycJ ��•4 % �� Capacity �,� 1 601 No. Compartments PKG. TREATMENT PLT. 0 � Method of Disposal Distance to nearest: Well A?C) Foundation AI Property Line l[, LEACHING LINE LI No. & Length of lines iC a L)f7 `� — Total length/size FILTER BED CI Distance to nearest: Well �y�,i1 f Foundation 1.C>_ Property Line «ZC^ r" SEEPAGE PITS 11 Depth Size _ Number SUMPS Ll Distance to nearest: Well!��'Foundalion '-r Property Line /21 DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that the work will be clone 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 workman's compensation laws of California." Contractor's 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 must call for all required insPection mplete drawing on reverse side. Signed X - J�� "- Title: (,L`ti;6,V/ �` Date: 3 FOR DEPARTMENT USE ONLY I% Application Accepted by � __ _ Date -3 Area -7, Pit or Grout Inspection by Date Final Inspection by Date i Additional Comments: Appll- ant. - 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 j FEE AMOUNT DUE AMOUNT REMITTED CK -7— INFO CAS RECEIVED BY DATE PERMIT N0. EH 13 24/ L j I H / EH14-Mtr1EV.rins) l / L.I L_ �/� �?//