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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 t P O BOX 2009, STOCKTON, CA 9520]. PERMIT-EXPIRES 1. YEAR FROM DATE ISSUED (Complete in Triplicate) le. - Application is hereby made to•San Joaquin County for a permit to construct and/or install the work herein described. This l application is made in compliance.vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San 4 Joaquin County Public Health Services. f Lot Size/Acreage Job Address . � City Owner's Name ]iV Address Phone — n Contractor I :Address Swettt Zt9 l 9- f License tio.S'41V- 7 3 Phone`9 9%1',A 917 TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION q Out of Service We11 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHERJ( Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK. ` SEWER LINES DISPOSAL FLD. PROP.. LINE Cl�m rh -� FOUNDATION -AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE _ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C"] Domestic/Private +% O Gravel Pack 0 Tracy Type of Casing_ Specifications I'1 Public El Other � n Delta Depth of Grout Sear Type of Grout 'Irrigation _,Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done —A—dd fill Well Destruction `❑ ' W611 Diameter Sealing Material 6 Depth Depth Filler Material & Depth C.CQ41w F, TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADDITION J.,l�1 DESTRUCT,ION I I (No septic sy em perms e i pu li w r is _available within 200 feet.) Installation will serve: Residence— Commercial— Other ; Number of living units: Number of bedrooms Character of &oil to a depth of 3 feet: I Water table depth SEPTIC TANK 0 Type/Mfg' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of Innes �¢ Total length/size FILTER BED Cl Distance to nearest: Well T Foundation Property Line \` I SEEPAGE PITS 11 Depth f Size Number y SUMPS 1:1 Distance to nearest: Well Foundation Property Line "- DISPOSAL PONDS 0 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 cenifies 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 mus all for all required inspection . Complete drawing on r arse de. Signed Titre: ti Data: _/� R NLY Application Accepted by ' Date ~ L Area Pit or Grout Inspection by Date� Final Inspection by Date 31 Z Additional Comments:�r AnD r Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 4 445 N San Joaquin, P O Box 2009, Stkn, CA 9S201 r , CK I ` lF 0 AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE (�) PERMIT'NQ. • EH 13-24(149v.1/A5) x'T�Q—O �� !w EH 11.28 !! ` r -