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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 Joaquin County Public Health Services. > G10��CI Job Address y Cit ��''� �n Lot Size/Acreaget1_��fy-9✓ �. _ —, —,— —_'�"=�` Owner's Name 5Z mom'` C&"X44&Address ��`�'' Phone Contractor Address License No.Vz%r_Phone tom) TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLAtEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 17 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing FI Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ — Specifications ('I Public fl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by �R1 Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth l.. Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ` _ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK 0 Type/Mfg Xd k Capacity 20,0 No. Compartments PKG. TREATMENTWT. O Method of Dispose l Distance to nearest: Well _ Foundation Property Line Ar*f LEACHING LINE C) No. & Length of lines 4—6 � � Total length/size_ Zan FILTER BED C] Distance Distance to nearest: Well-— Foundation _ Property Line- 510 SEEPAGE PITS I I Depth -Size 49L '( Number n SUMPS LI Distance to nearest: Well-+c-L26 Foundation Property Line DISPOSAL PONDS O 1 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 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 such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "1 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 mu or all required ins pe tions. Complete drawing on reverse side. Signed X Title: ��- �"' Date: r Air FOR DEPARTMENT USE ONLY �f Application Accepted by pp Date-�.�R ��_ Area �90r Grout Inspection by�s1 _ Date < � _ Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH 1� . EH13-24(REV. \ ��a �J� EH 14.26 V ./