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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 I Joaquin County Public Health Services. f `�/ / -' p Job Address 3ca`1 � f City �+' Lot Size/Acreage �0 x /7 F t Owner's Name E `f�D' rQ//16�s Address 2-3�,2` c/ Phone 0 WA.V47*0J 0 C4 .:$& Contractor LO+ Address f 0 _ _ License No. �V Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well _❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM7AREA CONSTRUCTION SPECIFICATIONS E3 Industrial ❑ Open Bottom 0 Manteca Dia. 6f Well Excavation Dia. of Weil Casing ["I Domestic/Private ❑ Gravel Pack 0 Tracy I Typerof Casing_ Specifications ' FI Public I-1 Other n Delta Depth of Grout Seal Type of Grout `v k I I Irrigation _.ApproK. Depth I I Eastefn,,_-,--_Surfaee Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done i Well Destruction ❑ Well Diameter Sealing !Material i Depth Depth Filler Material & Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR 1ADDtTIONX,, DESTRUCTION I 1 iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Y Commercial Other Number of living units: r Number of bedrooms { Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments { PKG. TREATMENT PLT. D �.... �� Method of Disposal ` Distance to nearest: Well Foundation Property Line ` LEACHING LINE No. & Length of lines (02 Property length/size / FILTER BED ❑ Distance to nearest: Well�� Foundation +_d[c_ Property Line J61, Ir SEEPAGE PITS 11 Depth Size �[ jTZ Number SUMPS 0 Distance to nearest: Well __ Foundation - t Property Line I 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 o►licensed a nt'a st nature 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 man r as to became subject to workmen's compensation laws of California." Contractor's hiring or sub contracting-signature certifies the folio ' : "1 certif t t in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o Ifornia." } The (cant must call f r ui d inspections. Complete drawing on r side. �= Signed �- title: '� .,.. .,.. Date: I QR DEPARTMENT USE ONLY 1 9 -� Application Accepted by '' Date : 2- Area Pit or Grout Inspection by Date Final Inspection by e G!' '�+sf Date Additional Comments U 10 ..•; .wt;.•tlos d- Applicant - Return all copies to: San Joaquin County Public Health services Z i Environmental Health Permit/Services ��;, 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE • ` INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. . EH 13.21 IREV,t/ns! f v , I ZZ IV f EH 14-Mu i