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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 Po[c• P O BOX 2009, STOCKTON, CA 95201 P P� 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 He./ 8a)lth vi s. t+ D Z( '- City `--'T Lot Size/Acreage )� Job Address Q Jl ` _3 Owner's Name 1 J re T yA Y &J Address V Phone Y17117 cs 7 Contractor t Addre �„ ' License No. 2373 -Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK f II0 r SEWER LINES 1'9'0 DISPOSAL FLD. PROP. LINE L_ FOUNDATION Z0 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION_SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavati n ' Dia. of Well Casing CA' mesuc/Private El Pack Tracy Type of Casing_ , 6oSpecifications FI Public Cl Other 171 Delta Depth of Grout Seal /OO Type of Grout B�pT�,tii c I i Irrigation —.Approx. DeptF},U I,li Eastern_ Surface Seal Installed by Repair Work Done ❑ Type of Pump -5 �S H.P. St a Work Dno Well Destruction ❑ Well Diameter Sealing Material i Depth Depth 25 Filler Material 8 Depth TYPE OF SEPTIC WORK: NEW INSTAL TION I I REPAIRIADDITION I I DESTRUCTION I I INa septic system permitted if public sewer is available within 200 feet.) 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 of Disposal t Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size* FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number ` SUMPS LI 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 f� rules and regulations of the San Joaquin County J Home owner or licensed agent'a 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." 1\ The applica sfc for all r d n ctions. Complete drawing on V Sid i Si ned X L/ '` V [_ Title: _ L��v r Date: -2 - Signed 2 g FOR DEPARTMIF T USE ONLY es d I Wt l 5" Application Accepted by Date Z— _ Area �-�� Pit or Grout Inspection by ion Date inal Inspectb Date ,[-- ► Z Additional Comments: t Applicant - Return a1 opies Y San Joaquin County Public Health Services Environmental Health Permit/services __445-N.-San Joaquin, P O.Box-2009;_Stkn, CA.-95201- -:6 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. IyN�FQ E /.�� / p� 1413.24(REV.I W 1'fe L g T��V 6? � 1-12 l-2—Qll]/ H 7420 /` W40 _� "