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l f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION l 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ` PERMIT EXPIRES 1 YEAR FROM DATE ISSUID (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 J County Public Health Services. r 3 cf Z� W De-LTA City Lot Size/Acreage C�e Job Address n , e Phone ,/� �,� t\�I� A drs Owner's Name ) 23, Contra + ctor !A'1 ��G1�E Address 1 S� ��oAl ��.i`ase No.��.�—..11� •—Phone � C� 1t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E-1,� DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well SEWER LINES DISPOSAL FLD, PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Wel! Casing 6 n Industrial [I Open Bottom ❑ Manteca Dia..of Well Excavation specifications Ci Domestic/Private ❑ Gravel Pack Ll Tracy Type rof Casing__ { A Depth of Grout Seal Type of Grout I"1 Public fa Other n Delta - 1I Irrigation __.Approx. Depth `I,l Eastern Surface Seul.lnstallad by �" *� Repair Work Done U Type of Pump H P State Work Done Sealing Material & Depth Well Destruction ❑ Well Diameter Filler Material & Depth r Depth ,� TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR�ADDlTION I } DESTRUCTION l I available-within-200 ble-within •200 feetc system rEted it public sewer is ,� f Installation will serve:"*Resdence Commercial— Other C Number of living-units: Number of be oms I :; AA) �( � II Water table depth I Character of soil to a depth of 3 feet: .__ / 4 SEPTIC TANK E�Type/Mfg Capacity � - r:No. Compartments y 1 , 14Method of Disposal PKG. TREATMENT PLT.❑ i >O I+ Distance to nearest: Well ! Foundation Property-Line` d LEACHING INE L� No. & Length of lines U Total lengthlsize FILTER BED C7 Distance to nearest: Well W Foundation Property Line O r 1 SEEPAGE PITS 11 Depth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ A", � I hereby cenify that I have prepared this application and that the work will be done in accordance with-San Joaquin county ordinances, state laws, and r rules and regulations of the San Joaquin County i Home owner or licensed agent's signature certifies the to "l certify that in the performance at the work for which this permit is issued, I shall not employ any person if California."n such manner as to become subject to workman's compensation lawsCaContractor'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 req inspect ns. Complete drawing on reverse side. i '7 Title: �Lle� k Date:- Signed j,✓1. j FQft DEPARTMENT USE ONLY t _. Date Area a Application Accepted by Date Final Inspection by Date�~Z� I Pit or Grout Inspection by - , _ 7I'll I Additional Comments: il 1116,1111 Applicant - Return all copies to: San Joaquin County Public Hlees Environmental Health permit/Services t 445 N,San�Joagvi-ny�P-OwBox�2t309-,_S-tknr CA_95201: FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY ATE PERMIT'NO. INFO + EH 13.24(REV,rin51 �� i EH 14.2E .