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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. _ ,�7 -_ Job Address � '4_R Q --Q big City_ Lot Size/Acreage JOIX Owner's Name T_R end-� -- Address d INT Phone Contractor ` L-Aa,Address Ro• &L YQ Cod 77-License Nop„�q—y—M3 Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT E DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR C OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK Q 17 SEWER LINES DISPOSAL FLD. PROP. LINE //,,,., AGRICULTURE WELL OTHER WELL PITS/SUMPS/,3 — FOUNDATION_ A E- ---.-.----____-- i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS yr f-1 Industrial Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing XDomestic/Private ❑ Gravel Pack C3 Tracy Type of Casing_�G,e- r Specifications F1 Public 1-1 Other Cl Delta Depth of Grout Seal Type of ►out lt�eet� I I Irrigation �C Approx. Depth�I�I astern Surface Sedt installed by 11 ex I �° Repair Work Done U Type of Pumper l H.P. _ State Work Done - �Q Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is _ available within 200 feet.i Installation will serve: Residence____ Commercial-__._ Other mss! Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth n SEPTIC TANK ❑ Type/Mfg Capacity------ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L] No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS C1 Distance-to nearest: Well.- Foundation Property Line.— DISPOSAL __ ... 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 taws, 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_must call for all AY /uired i spections. t'omplete drawing on reverse side. Signed X_�' ��p 1�11n,t AQQV✓ Title: /�tf-S Date: O TMENT USE ONLY r� q Applicattiio''��n Accepted by Date y {Z aArea- Pit or¢rylut Inspection by "Date . 3' -C Final Inspection by r!I4Z��d Date-/ f 2� 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 iN O AMOUNT rDUE AMOUNT REMITTED CASH KIf F ECEIV BY A1TE E IT'NO. /f;^f/�� . EM 17.21 IREV,r r x st 3 t,{ r t�1a C^gy fj L Y yI EH 14.26