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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 G PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 11A (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 Publi Healt Services. City " ` r Lot Size/Acreage Job Address e p Owner's Name Address 3880 'uM Phone Q' J< !nLicense No� 0 %0 Phone Contractor-,� S�,-K ` - --'--Address A- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHO WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIONS IFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well E vation _ Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of sing_ Specifications I'] Public [_1 Other n Delta De of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern urface Seal Installed by Repair Work Done L] Type of Pump H.P State Work Done _ Well Destruction ❑ Well Diameter Baling Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Z Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ¢ 1 LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line C2 SEEPAGE PITS 11 Depth Size _ Number \^ SUMPS LI Distance to nearest: Well Foundation Property Line Y' DISPOSAL PONDS ❑ 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 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 m t call for all re .edlins 7111ons. Complete drawing on reverse si e. Signed X Title: Date: 3-v�� FOR DEPARTMENT USE ONLY Application Accepted by - �� tt - a Date Area Z� Pit or Grout Inspection by Date Final Inspection by Date ,. Additional minents: Ap cant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 8 CASH RECEIVED BY DATE PERMIT'N0. INFO (T19 R AVX--, 9 . EH 13.24(REV.rixa) �.p� l.0 `' "'� EH 14.2a SDI