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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX-2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sen 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 Joaquin County Public Health Services. ` Cit Lot Size/Acreage f Job Address �J V Owner's Name - "s r ddress Phone Contractor '? ddressLicense No, /�a� Phone TYPE Of WELL/PUMP: NE WELLr3 WELL REPLACEMENT . DESTRUCTION Out of Service Well ❑ ks PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER Q Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK 0[�' f SEWER LINES "�—� DISPOSAL FLD. -7_7 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ' 'PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E( F1 Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing 51 XDomesticlPrivate Gravel Pack L] Tracy Type of Casing_ P 1 Sogcffications.'-.I:::/— '00f401 Il Public �, � ,., : !: ther �Jl�� n Delta Depth of Grout Seal � ft/TI�R*yLpeof Grout I I Irrigation •t ppr x• Depth t I Eastern ace Seal installed by _ I Repair Work pone C] �Type of"Pump "H.P. "� _ 'State Work Done j 4 Sealing Material & Depth .e�t.5a_la, Well Destruction=. Well Diarrieter _� T ` Depth, v Filler Material & Depth A r Tl�� /�►� �C� � i TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1. REPAIRIADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is _ available within 200 feet) Installation will serve: Residence'_ Commercial_ Other ' Number of living units:-L--/Number of.bedrooms Character of sail to a"depth of 3 feet: i Water table depth SEPTIC TANK ❑ Type/Mfg t Capacity No. Compartments . ..�. PKG. TREATMENT PLT. Cl v - Method of Disposal Distance to nearest: Well "Foundation Property Line LEACHING LINE y D No. & Length of lines T Total length/size f FILTER BED ❑ Distance-to-nearest., Well` Foundation Property Line 1 y SEEPAGE PITS 1-1 -Depih Sire Number Is SUMPSLl S�pistance to nearest: Well Foundation Property Line `a DISPOSAL PONDS C� f ► \ I 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 i 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 manrier as to become subject to workmen's corripansation 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." y The applicant s/ II re�e� tions. Complete drawing on revers _ide, i J� Signed X �•„�, �.�-TKtle: .� Date: FOR DEP RTf1AENT USE ONLY I Application Accepted by/ Date z-Area s �/ a Pit Gro inspaction by Date 2y_1 Final Inspection by 6 • Date 9� Additional Comments: be"a;mf, A— ��- (L itt,�qq-tv) _ - ... Applicant_-�-Return I -all copies to:^�San-Joaquin' County`Pub11c HealtEi"Services Environmental Health Permit/Services f 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 fEl INFO AMOUNT DtJE' AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT'NO. 1 W AJ 6?0 �, -.2341 EH 13.2 (REV. 1"51 EH t4-2a F IV