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i I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .i (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/ �r �,� Job Address _ ! �� '" � ��rr�2 City - Lot Size/Acreage Owner's Name J G` 4 Address /V, D -�� Phone M � Contractor T ., I1r1�- fes liN Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL-REPLACEMENT n DESTRUCTION o Outi;bf Service well ❑ • ------PUMP-IN STAL-LATiON.❑---. SYSTEM REPAIR_L] �l� OTHER E) ' Monitoritsg Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , DISPOSAL FLD. PROP.IINIE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/S MPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` C1 Industrial ❑ Open Bottom ❑ Manteca __--Dia.-of-Well Excavation Dia. of Well Casing * DomesticlPrivate O1 Gravel Pack7 ❑ Tracy Type of Casing_. Specifications I'I Public F1'Othei—' '* ' n Delta Depth of Grout Seal Type of Grout I # Irrigation '�"'Approx. Depth I I Eastern Surface Seai installed by Repair Work Done L] Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter ;Sealing Material Depth j Depth IFiller material 615epth I TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 EPAIR/ADDITION E w DESTRUCTION I i lNo.septic system permitted if public sewer is f -';available within 200 feet.l Installation will serve: Residence V Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: -L'-Water table depth SEPTIC TANK 13Type/Mfg, rpt T ffCapacity . .Na. Compartments Disposal PKG. TREATMENT PLT. ❑ ;I .�„F F . Method of Distance to nearest: Well `Four biflon Property Line • i LEACH114G LINE No. & Length of lines _ Total length/size FILTER BED 0 Distance to nearest: Well Foundation _tL_+- Property Line^SJR SEEPAGE PITS 11 Depth Size Number_.'t SUMPS GI Distance to nearest: Well Foundation .Property Line ° �DISPOSA•L PONDS ❑'- I hereby certify that I have prepared this application'and`ihat 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 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 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 call for all required inspections. Complete drawing on reverse side. Signed X 1 'LuellT� Title: _� �� __-__ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date /J `� �� Area !1 Pit or Grout Inspection by Date Final Inspection by Date `[ i Additional Comments: i Applicant. - Return'all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE I INFO AMOUNT DUE AMOUNT REMITTED CK RE EIVED BY AfTE PERMIT'NO. EH 13-21 IREV.4 K 5 6D �J�7 EH 14-25 lJdd i J, i � J