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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.ito San Joaquin County for a permit to construct and/or install the work herein described. This application is made in coup-lance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Fi��uc !ate x 9 Job Address Q � ��d.t?� _ City L�.wf P_ Lot Size/Acreage Owner's Name I�L Address .C- Phone Contractor P4,aWD oeD Address- 7 Al, A D.GL44z—,_z License No. 42-3-2-76 _ Phone}d - TYPE OF WELL/PUMP: Ij NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ � SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE 1. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing FI Domestic/Private ❑ Gravel Pack7 C1 Tracy Type of Casing_ Specifications I'I Public f-1 Otliler ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth'� Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I l INo septic system permilted H public sewer is available within 200 feet.) Installation will serve: Residerice Commercial_ Other). _ La T- a� 2E c_o.eD P210,2 Number of living units: __.�_11�� Number of bedrooms 3 �. Tb l 4 7.Z t Character of soil to a depth of-3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg to ' Capacity 12C�e7 No. Compartments 2- PKG. TREATMENT PLT, ❑ I� Method of Disposal Distance to nearest: Well -50 Foundation `tea Property Line ZA2 _ LEACHING LINE L"f Ntil & Length of linea 3 �gra Total length/size -7-42 O FILTER BED n Distance t6 nearest: Well Foundation Property Line 3 IM ' SEEPAGE PITS I'I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ IN I hereby certity that I have prepaf`ed 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 of 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 sny 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 tli°at 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." 11, The applicant must call for all required inspections. Complete drawing on reverse side. ,Ik Signed x � Title: � � Date: I� -FOJBODEPARTVENT USE ONLY Application Accepted b Data �`r a Pit or Grout Inspection by I�. Date Final Inspection by Additional Comments: Applicant - Return a11_1copies to: San Joaquin County Public Health Services tEnvironmental Health Permit/Services i 445 N San Joaquin,-P O'Box 2009, Stkn, CA 95201 FEE i INFO AMOUNT.DUE AMOON7 REMITTED CASH RECEIVED 183Y DATE PERMIT'NO. EH 11.20 �I I`.