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1 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 Sae Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Lot Size Job Address gr 1fNy g tl�//Vaf+� � A�5 City � /Acreage C�r�. yrj$"RAJ P ■5� Add ss M"Zs" 4-M 4535 Phone � 6 Owner's Name . Z �5 #" M 1 .$ x K 1 rJ �APjI 445'T7 14 Eld Contractor SPECI&M Address License No.vWfaPhone TYPE OF WELL/PUMP: NEW WELL Z WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well LI SYSTEM EPAIR C7 OT ER ❑ Monitoring Well PUMP INSTALLATION ❑ t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES N DISPOSAL FLD AJ PROP. LINE 3� FOUNDATION !j-7— ' AGRICULTURE WELt N OTHER WELL� b PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS tit n Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing T:1 Domestic/Private ❑ Gravel Pack Tracy Type of Casing—PVC, SpecificationsH _ r I'I Public IVOther n Delta Depth of Grout Seal 5 _ ._ Type of Grout I I Irrigation ►moi Approx. Depth I I Eastern Surface Seal installed by R�9 NR M Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material 4 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I iNailabetic shin system emitted if public sewer is 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 Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 8 Length of tines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property tine 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: "1 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 subcontracting signature certifies the following: "I certify that in theperformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mus all far all require r cti n reverse side. C Signed X Title: —A '�Y ��'Z 3 Date: FOR DEPARTMENT USE ONLY /f Application Accepted by 'J Date ' ' 1 Area (ln l Pit or Grout Inspection by DateFinal Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services /] Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CKS CASH RECEIVED BY DATE PERMIT'N0. INFO . EH 1321 tREV,t i It s) Do M 58too M.M . -4.21.g2. 152-:2575- 1 EH 14.20