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I� E ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , ENVIRONMENTALI HEALTH DIVISION I 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 to made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I� - Job Address Lot Size/Acre�� "•"" ' City age Owner's Name Address klU ___ Phone a I 2$ Z Z-Lp Phone �F;ry. � � I License No. Gontsact Address tTYPE`OF WELLlPUMP. NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION L'} Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHER ❑ Monitoring Well C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES", DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE?WELL OTHER WELL PITS/SUMPS —INTENDED USES TYPE OF WELL��PROBi-EM AREA^-CQNSTRUCTION SPEC-IFIGATIONS---=�— Cl Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing E fl Domestic/Private ❑ Gravel Pack_ _ C] Tracy Type of Casing_ Specifications I'1 Public 1-1 Other 171 Delta Depth of Grout,Seal Type of Grout I I Irrigation Approx...—Depth L I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump` H.P. r .-- -- State Work Done_. v b 0<3 Well Destruction ❑o, Well Diameter �'��y Sealing Material Depth •� Depth Filler Material b Depth ,;y - TYPE OF SEPTIC WORK: NEW INSTALLATIONI 1 REPAI ADDITION ,r01=STRUCTION I i (No septic system permitted if public sewer is II - available within 200 feet.) Installation will serve: Residence'— Commercial_ Other " I Number of living units: Number of roo' t� Character of soil to a depth of 3 feet: Water table depth 915 . r - SEPTIC TANK Type/Mfg ' Capacity ®Q No. Compartments PKG. TREATMENT PLT. ❑ f" ak s Method of Disposal r . Distance to nearest: '.Well+�0 a Foundation Property Line LEACHING'LINE ❑ No. Length oiAhn'ss , _'- - " Total length/size c� FtLTER BED - Cl Distance to nearest: Well 11 Foundation Property Line SEEPAGE PITS X 4r Depth — Size .:. -. lumber - SUMPS Ll Distance to nearest: Well- $f2 _ Foundation Property Line DISPOSAL PONDS ❑ I ^� I hereby certify that i have prepared this application and that the work will be done in accordance'with Says-Joaquin county ordinances, state laws,_and -=��rules-and regulations-of-the-San;Joaquin County ,d� f r.•..;. � y�� ''��'°�� -"" -- 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 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 diu call for al a u inspections. Complete drawing on reverse side%* 11 [ f� Signed Title: VP . Date: ` v FOR DEPARTMENT USE ONLY / Application Accepted b Date G 7-y Area r ; CW/Or Grout Inspection by Do (Fine! Inspection by Data Additional Comments: E � Applicant - Return all copies to: San Joaquin County Public Health Services i Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 .EI FEE AMOUNT DUE AMOUNT REMITTED 1CK RECEIVED BY DATE PERMIT'NO. INFO .l CASH . EH 13.24 IREV.i/NS EH 11.2E � is