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SAN JOAQUIN Co IC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N-SAN ,JOAQUIN, `PHONE (209)468-3420 P O BOX-2009,S TOCKTON,;,CA 95201 PERMIT EXPIRES ]. YEAR FROM DATE ISSUED (Complete-in Triplicate) 3 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 vith_San Joaquin County ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. p� �f1A C �O City�"1A 0#0'E�v Lot Size/Acreage Job Address ` !►L ! -�2 Address S P"Vyiam Q S Z3 fo Phone Owner's Name 1 Phone Contractor Address CA-.i License Pie. l� TYPE OF WELL_/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION L�"Out of Service Well. LI l OTHER fD Monitoring Well PUMP INSTALLATION �rF;'` SYSTEM REPAIR ❑ � DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE P FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE.OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing p L7 Industrial ❑ Ops Specifications L l kL4�lomesticIPrivate ❑ Gravel Pack ❑ Tracy Type of Casing- I'i Public f-1 Other n Delta Depth of Grout Seal Type of Grout I,I Irrigation Approx, Depth I I Eastern Surface Sedl Installed by Repair Work Done U Type of Pump H.P. State Work Done Sealing Material A Depth Well Destruction ❑ Well Diameter 1 t Depth .t Filler Material A Depth am TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I (Noavaseptic shin 200 feet.) ed if public sewer is Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms_ --.-,r,., n ";''-Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TRCATMENT PLT. DMethod of Disposal 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 Site 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 rules and regulations of tris San Joaquin County Home owner or licensed agent's signature certifies the fallowing: "I certify that in the performance of the work for which this permit is issued, I shall not empioy 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 st call for all required inspections. Complete drawing oazr4 C�+ f � f%l� Date: Signed Title: �-. t FOR DEPARTMENT USE ONLY Application Accepted by Date=`9%:::gL _ Area Pit or Grout Inspection by Date Final Inspection by Date �� Additional Comments: Applicant - Return all copies to: San Joaquin County Public health Services Environmental Health Permit/Services i 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. jI�NfO7 /�/ +7 . EH 13.21(ACV.rix ss 1/j[ �P �� f/" ©� EH 11.28 1 I" 4