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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 Be ices. Job Address C'Cik=+� �N City Lot Size/Acreage r Owner's Name 490)4R11 Address V Phone Contractor Address P-o icense N hon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR '❑ OTHER O Monitoring Well 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 O Manteca Dia. of Well Excavation Dia. of Well Casing 1:1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications i"I Public Cl Other n Delta Depth of Grout Seal Type of Grout .� I I Irrigation _.Approx. Depth I 1 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I IN;o septic system permitted if public sewer is available within 200 feet.) Installation.will serve: Residence Commercial —Other, Number of living units: Number of bedrooms_ r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments AKo ^` PKG. TREATMENT PLT. ❑ ` ( �Q Method of Disposal �> Distance to nearest: Well O Foundation "Property Line fi LEACHING LINE ❑ No. & Length of linesTotal length/size 6 FILTER BED n Distance to nearest: Well� Foundation 'Property lipe' zli SEEPAGE PITS I I Depth Size x Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ •« wy I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin Bounty 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 to become subject to workman's compensatio of California:"Contractor's hiring or sob contracting signature certifies the followin rtify that the nce of the work for which t ermit is issued,I shall employ persona subject to workman's compensa- tion laws of Californ a." The applica^ all for I requir inspections. omplete drawing on r erse side. Signed A k C Title: Date, FOR DEPARTMENT USE ONLY Application Accepted by i&d4 KDate, Area z� Pit or Grout Inspection by Date Final Inspection'by Date Additional Comments: tead, lute's te— ,10- p- // it U/l v✓i o{' eB.C4, 4.),u- . Applicant - Return all copies to: San Joaquin County Public Health Servicesf�K Q- Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201, FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT''NO. INFO CASH . EH13.24(REV.v e 5)�t / 11 Loi 0_ �L �D KIM0- .. �'� EH tt-Ia ,v �