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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)465-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED co G l je.K (Complete in Triplicate) Applicationr by trade to San Joaquin County for a permit to construct and/or install the work herein described. This application ie de in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San r Joaquin County blit HealthJU e i Job Address City Lot Size/Acreage Owner's Name 1I Address 0. Phone f� F Contract Address- 1' `'� �� •License No3?�7Z Phone IaS TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION.0— :u .SYSTEM REPAIR. L1 _ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSALrFLO.x� PROP. LINE T } FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r G-] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing D Domestic/Private 0 Gravel Pack7 n Tracy , -Type of Casing= ---- -Specifications Il Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approk. Depth i I Eastern ;;Surface Seal Installed bye Repair Work Done 0 Type of Pump H.P. State Work Done _ 2 Well Destruction ❑ Well Diameter Sealing Material k Depth t Depth. . .. - _ Filler Material b Depth ' ..•.�,�_..Yy , ..-. . �. �_.. TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 DESTRUCTION I I iNo septic system permitted if public sewer is / available within 200 feet.) Installation will serve: Residence v Commercial_ Other T"w' Number of living units: _J— Number of bmdvooms Character of soil to a depth of 3 feet: "pr' Water table depth lSlS6 , SEPTIC TANK Type/Mfg CapacityNo. Compartments PKG. TREATMENT PLT. Cl ,..r t Method of Disposal Distance to nearest: Wel!_ LLL Foundation �) -^�# Property,Line { ` LEACHING LINE No. & Length of lines — �' ="+ Total length/size X FILTER BED C-I Distance to nearest: Well '561 , Foundation ra Property Line S SEEPAGE PITS Depth Size i Number , �,.__J _ _ SUlulp$" -' � l:l Distance to nearest; Well�_... Foundation' 10 .Property Line DISPOSAL PONDS ❑ ��. j I hereby certify that I have prepared this application and that the work will be donwin accordance With San Joaquin county ordinances, state Jaws, and rules and regulations of the San Joaquin County I 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." 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 t Call fora re fired inspections. Complete drawing on reverse side Signed X Title: _-- e Date: `.�� %C& FOR DEPARTMENT USE ONLY Application Accepted by Data `��9^72 6�F Area f 2- Pi or Grout Inspection bi ateG�- Final Inspection by Additional Comments: ' • R Applicant -- Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services J F ; 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 '- } � 1 . FEE AMOUNT DUE AMOUNT REMITTED CIC RECEIVED BY OATS YERMIT'NO. "`-� INFO f I / CASH • . . FM 43 24 Ir1EV. n 5 d l �i d G v� T EH i{•20