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l w SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION f 445 N SAN JOAQU IN, PHONE (209)468-3420 P O BOX 20092 STOCKTON, CA 95201 . r ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l (Complete in Triplicate) k 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I�r7 Job Address Z Z 77 6102 ,-1 City ✓�� W Y Lot Size/Apcdr�eagee �}Q 1�(/ rf �C LIQ 131 01{ [ e D -:1 U ph ew Owner's Nama�j'j Address O Contractor 1'►a r+{nyu Address � PP IL � icense No. �" � Phone TYPE'OF WELL/PUMP: NEW WELL WELL REPLACEMENT 1-7 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR C7 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 4 1a FOUNDATION AGRICULTURE WELL �:OTHER WELL PITS/SUMPS IN USE TYPE OF WELL PROBLEM AREA "C014STRt1CTION'SPECIFICATIONS Cl Industrial BYO Open Botto-��m"—"""`❑ Manteca T'Dia:of�Excavftion —^—�...Dia._of.Well Casing /A Domestic/Private ijLGravel Pack ❑ Tracy Type of Casing_ Specifications — Il Public Cl 0{ i l pelta Depth of Grout Seal 1 a �____— Type of Grout f ig I I Irrigation .IApOepth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump SULAM H.P. It b. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth ' "t Depth Filler Material &±Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i IIVo septic system permitted it public sewer is available within 200 feet.) j Installation will serve: Residence_ Commercial— Other ) 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments .. PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation 'Property Line r " SEEPAGE PITS 11 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line I DISPOSAL PONDS ❑ r 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 rules and regulations of the San Joaquin county Home owner or ricensed 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 Califor The applicant t tail for all required in". i S. Comple drawing on reverse side. r t Signed ' "� Title: Date:lop, 01 s + FpR-DEPARTMENT USE ONLY t Application Accepted by Date 17�3 rea .7' Pit or Grout�Inspecctiiap byy w Date 'a" 3) 'nal Inspection by w' Date Additionpl-Com�m�ants: v ` �"• „'l Applicant - Return all copies to: San Joaquin County Public Health Services /t I q _./,Z Ll f �4 f.,t Environmental Health Permit/Services C� 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 de t� JtO w /// FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH . EH 13.24(REV.I'Asi NAla EH 14.26 r s _