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SAN JOAQUIN. COUNTY PUBLIC' HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 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 work herein described. This application is made in compliance with San Joaquin County ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. . 1 Job Address �., - /4- )A16, City Lot Size/Acreage Owner's Name �V ----- Address �✓ Phone i Contractor��LrJC.i.L' Address 76 License No.r�/.�Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT C-1 DESTRUCTION D out of Service Veil Wr k rSYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ PUMP INSTALLATION ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FI-D. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS In Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation __ Dia. of Well Casing i '[-I Domestic/Private CI Gravel Pack n Tracy Type of Casing_ Specifications Il Public EI Other. n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth t I Eastern Surface Seal Installed by s, State Work Done, Repair Work Done C7 Type of Pump H.P. Well Destruction D :Well Diameter (� Sealing Material & Depth Depth Filler Material3 Depth `V DESTRUCTION I I INo septic system permitted if public sewer is TYPE OF SEPTIC WORK: y.NEW INSTALLATION IREPAIfllADDITION ; VT available within 200 lest,i i Installation will serve: Residence_e Commercial_ Other ; 'I Number of living units: J Number of bedrooms �t p� - Character of soil to a depth"of 3 feet: . —Al��_�L-�{l Ca Qs�=—x' - Water table depth SEPTIC TANK ❑ Type/Mfg _ - Le __ Capacity No. Compartments 1 PKG. TREATMENT PLT. ❑ ��,., • Method o4 Disposal Z I Distance to nearest: Well L.2 Foundation. Property Line r LEACHING LINE No. 8 Length of lines 'Notal-lengthl-size FILTER BED ❑ Distance to nearest. Well -F6undatton Property-urie— SEEPAGE PITS 11 Depth Size Number K SUMPS C1 Distance to nearest: # Well Foundation Property Line r R- DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and-that the work will be done in accordance with San Joaquin county o_rd_inances,state laws, and rules and regulations of the San Joaquin County .r- I ' Home owner or licensed agent's signature certifies the following;,'-1 certify that,in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject.-Io workman's compensation laws of California," Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of•the.virork for which-this permit isissued, I shall employ persons subject to workman's compansa I tion laws of California." ( ~' The applicant must call for a r ired;inspections. Complete drawing on reverse side. Q Signed X w. Title: Date: FOR DE USE ON . .- �..a' Application Accepted by t Date Pit or Grout Inspection by Date Final Inspectiori.by.'` _ ate 3 _. Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O' Box 20091,'�Stkn,' CA 95201 ! - ,. �.•_._.�......_.,mss..,^.. ..._...,,-.. �--- _,y-,,,....... w r AFEEE AMOUNT DUE' AMOCINT'REMITTED RECEIVED BY DATE PERMAIT'NO. Eli 13-Z4 IREV.v i N 5) f Et+1 .24