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i 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 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. `��y l� �� S/r� City_ -` ` I Lot Si Acre e! Job Address f �= A4 Owner's Name — xe> Address Phone co. � ` Phone Contractor tt,E Address w License No, P or service Wei! 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL'. PROBLEM AREA CONSTRUCTION SPECIFICATIONS i # p•0' n Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing �..� n Industribl','""` pe r` s - } g a ` F Type of Casio Specifications ^^-�• t7 Domesticl Private`; --'Ll.Graveh 8 Pack ,r -❑ Tracy _ — I'1 Public , l:1 Other °r : n Delta Depth of G,,761 Seal Type of Grout '`' -� i I I Irfigation —.Approx., epth I I Eastern Surface 9 61 ,Installed by H P .a k`10 -State Work Done [� Repair Work Done L7 Type of PUMP t, � k ,,; �"'Sealittg Material & Depth� ' r Well Destruction ❑ Weft Diameter ,. ..,, - irpt ..�.. t Depth ''Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ! I PAIFI! DDITION' available I DESTRUCTION l I system permitted if public sewer.is ,f availabllee within 200 feet.l Installation will serve: Residence— Commercial—Other' tl fi Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: _ `Water table depth Capacity No. Compartments k SEPTIC TANK. ❑ Type/Mag � y PKG. TREATMENT PLT. ❑ x ,�, ;" Method of Disposal Distance to nearest: Well Foundation PropeRy Line LEACHING LINE No. & Length of lines Total length/size' FILTER BED nDistance to nearest: Well Foundation $.bLm.--_ Property Line _ SEEPAGE PITS I I Depth Size Number a SUMPS1. Distance to nearest: ' Well —1--"Foundation 104— Property Line DISPOSAL PONDS ❑ I hereby certify that f 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 Y 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 taws 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," The applicant must II f r- II Vtlired inspections. Complete drawing on reverse side. f �11 � f � -- t/Y��t�'�--� Date: Signed )C "''" "�" "Title: ` C DEPARTMENT USE ONLY r Application Accepted by Date. 2 '�� 7- Area Pit or Grout Inspection by Date Final Inspection by 1 Date .'9 Z Additional Comments: U F t r q t 1-2 Applicant -- Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services S 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 CK 8t FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PjRR ;T �] INFO ,yy r .EH 13-24 MEV.Fina)S� 1 , .©O • c, EH 16m �Tll