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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 22 ENVIRONMENTAL HEALTH DIVISION 1 1 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I 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 1862 and the Rules and Regulations of San Joaquin County Public Health services. Job Address L 6 � City Lot Size/Acreage e�f✓ a-G` - �� —(A� � �] 1S A In Y► 1 P ��l 2 �.� Address ! �jam'` 7-8 L -:7�j Z VV j Phone Owner's Name Contract or . Address R #�� Lic f 1C_P_q _3 Phone `� LITYPE OF WELL/PUMP: N W WELL ❑ WELL REPLACEMENT n DESTRUCTION Out of Service Well PUMP INSTALLATION © SYSTEM REPAIR ❑ OTHER ❑ Monitoring well Pt SEWER LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST SEPTIC TANK _ � _ FOUNDATION AGRICULTURE WELL OTHER 1NElL PITS/SUMPS'; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing C7 Industrial ❑ Open Bottom ID Manteca Dia. of Well Excavation Specifications. C.1 DomesticIPrivate ❑ Gravel Pack7 0 Tracy Type of Casing_ Type of Grout I'! Public 1-1 Other n Delta Depth of Grout Seal I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of i_ _ r H.P. State Work Done Scaling Material b Depth '- Well Destruction Well Dia / �/��, j Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ! DESTRUCTION I I INoave septic system permitted it public sewer is available within 200 feet-I \ Installation will serve: Residence Commercial_ Other l Number of living units: Number-of 7tiedroor`ns r 1 Character of soil to a depth of 3 feet: �m Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity - No.7Compartfnents PKG. TREATMENT PLT. ❑.. V - - `Meihbd of Disposal— Distance to nearest: Well Foundation Property Line '- LEACHING LINE C1 No. & Length of lines Total lerigthlsize s ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line e SEEPAGE PITS 11 Depth Size Number a SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 ruses 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." Contractor's hiring or sulci-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 mu scall for all equ'ed in tions. Complete drawing on reverse side,.. Signed )h.G��' A Title: - e /1/,/� 5 _ Date: C7 I F DEPARTMENT USE ONLY Application Accepted by0%4 v`^ - Date e8 — Pit or Grout Inspection by Data r r Final Inspection b y fla��% C'!" .�� I Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services t 445 N San Joaquin x 2009, Stkn, CA 95201 ZFEE MOUNT DUE AMOUNT REMITTED CA ql RECEIVED BY D TE PERMIT'.140. 1 INFO � , rt7l- A7 EM13-24(REV.tinal t_r g e *� EM 14.26 W l.�