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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. I% Job Address 'Z 9.21 Ad*V,*XV - City AVGAL01V_ Lot Size/Acreage Owner's'Name � � Address 046VA9'dJ d Phone Contractor AWr ON 'f_4e1V Address IWX 6Gtlt' a� eve'' License No. `;fVr_J 1 Phone TYPE OF WELLIPUMP: NEW WELL D WELL REPLACEMENT Fl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR Ll OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 5 Industrial 0 Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing Ca Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications 1'i Public El Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seul Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction p Well Diameter sealing Material & Depth Depth Filler Material Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 2W feet.) Installation will serve: Residence L Commercial_ Other Number of living units: __L Number of bedrooms y Character of soil to a depth of 3 feet: 4!'- m Water table depth SEPTIC TANK 90 Tvpe/Mfg AAVep gidf'T e Capacity ADOn No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation r0 Property Line ' LEACHING LINE Wf No. & Length of lines $ v yap Total length/size E 30 FILTER BED n Distance to nearest. Well Od Foundation O Property Line SEEPAGE PITS 11 Depth �� Size X /O Number SUMPS M 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 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 mu t call for all required inspections, Complete drawing on reverse side. Signed X Title: Date: FOR D USE ONLY Application Accepted by Date L�'' Ar Pit or Grout Inspection by Data final Inspection by at Additional Comments: 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 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DA,E PERMITNO. . EH14.26 -24 iREV.I/x 5) � // / �✓ C//v /� c/ L/ EH 14 i