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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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. /� J. frmp kick City �� Lot Size/Acreage�so t 2� Job Address aa Address Phone t Owner's.Name •. Contractor -uFol,. UL416 Address � � [JI'MW 0411&nse Nolqkja_Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well 0 PLiMP INSTALLATION OV -7 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE .,r� .. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SLi`MPS k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fa DomesticlPrivate ❑-Gravei•Pack - ,...._.C7 Tracy rType-of-Casing_ Specifications — c Public F Cl Other ""' ..rn Delta Depth of Grout Seal Type of Grout I I trrioation 3 Approx. Depth I I Eastern : Surface Seal Installed by Repair Work Done U Type of Pump= - - - •�-H.P• — State Work Done TNN �- �---r= -Sealing-Material &'Depth Well Destruction ❑ -Weil Diameter i Depth Filler Material & Depth ' TYPE OF SEPTIC WORK: NEW INSTALLATION fiEPAIRlADDITION I ! DESTRUCTION i I lNo septic sys[em permitted it public sewer is available within 2t. feet.) Installation will serve: Res/idence commercial Other ' Number of living unit's: __L___ Number of be 0'0-M'S .r } Character of soil to a depth-of 3 feet:-'��Aam y - -Water table depth SEPTIC TANK; ❑T Type//WNg'- T Capacity V n No. Compartments PKG. TREATMENT PLT. ❑,� r , Method of Disp sal Distance to nearest: Well-50. Foundation S Property UKIa �b y LEACHING LINE No. & Length of lines 0 Total length/size FILTER BED n Distance-to-nearest: Well. -- - Foundation Property Line r SEEPAGE PITS I; Depth. Size / Number. LIMPS f LI Distance to-nearest: Well Foundation Property Line 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 certifie 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 ubject to workman's-compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the perfo ance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." F The applicant mus for all r ' d In",.. ons. Complete drawing on reverse side. Signed X Title: Date:Zf �� FOR DEPARTMENT USE ONLY Application Accepted by496ts Date rsa d ' Pit or Grout Inspection by Date Final Inspection b Data i� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445.-N-.San-Joaquin;YP-0-Box-2009,Stkn, CA-95201f FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. r INF o� f� * d2 EH 11-2a EH 13-24 INEV.1;.Sf I -