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_r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P O 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 J aquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servi :F 3fvt5�r�Gc(�dt Address Lot Size/Acreage Job titv Owner's NameCA Address U Phone It el(J Contractor Address License No. Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION WOut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 9TKER C] Monitoring Well G7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _._�� DISPOSAL FLD.t "t' PROP. LINE FOUNDATION AGRICULTURE WELL rs.[.G-- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ OpKeotlorn ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C_t Domestic/Private w6ravel Pack 0 Tracy Type of Casing_ Specifications I'! Public [I(Other n Delta Depth of Grout Seal Type of Grout 101"19ation 6cc—Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7Jr/�of Pump — H.P. - State Work Dane Well Destruction Well Diameter U Sealing Material & Depth 1 r Depth +" Filler Material 5 Depth i I [t TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRU ON I I 'No septic system permitted it public sewer is available within 200 leet.l Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method oR&v rmbjT- Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size A 0 1 1992 FILTER BED 0 Distance to nearest: Well Foundation Property LVACC J(DAQ,I II_NI CO!.JNTY PURL-I% HEALTH SF.kVICES SEEPAGE PITS 11 Depth Size Number ENV1R0NMENTAL HEALT F4 LAVISICA SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 rules and regulations of the San Joaquin County Home owner or licen d agent's signature if' the following: "I certify that in the performance of the work for which this permit is issued, I shall not empioy any pars* i uch manner as to me subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature cartifies the folio : "I carti that in th rtormance of the work for whit this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cal la." The appl' ant t call f Gompiete drawing on a se si r Signed Title: Date: FO DEPAR7iVIEN7 USE ONLY Application Accepted by Date L Area Pit or Grout Inspection by �] Date Final Inspection by Date I /_ ? 2- Additions! Comments: �r�/ Z Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services �J 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 aFEEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM11'N0. EH 13,24iREV.t/x5) �EH t4-26