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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION - 3 � 445 N SAN JOAQUIN, PHONE (209)468-3420 /� N� P 0 BOX 2009, STOCKTON, CA 95201 "'JJ 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. e e Job Address 22- � A4t1 t-t City /` Lot Size/Acreage /�'4-."ey Owner's Name t t)auc'fley` Address ' � �m f'Y Phone f �t ( lrll ddress "� t /► �License No, T.. � L Phone Contractor 11�' � -+�� TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLAT N O SYSTEM REPAIR O OTHER O Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.�f PROP. LINE FOUNDATION1V&'L AGRICULTURE WELL l k - O OTHER WELL /y�,.f PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom C1 Manteca Dia. of Well Excavattii�o,nDia. of Well Casing C.l Domestic/Private &,Gravel Pack I-] TracyType of Casing-o��" Specifications I'1 Public Cl Others r n Delta Depth of Grout Seal � f2 Type of Grout '� Zo,:�(,rrigation pprOx. Depth I I Eastern Surface Seal Installed b1AJA.Cel 'p Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 11 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number _ ti SUMPS LI Distance to nearest: Well Foundation Property Line 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 st call for all required ins tions. Complete drawing on reverse side. Signed X 2 L /� � Title: `�k ZL 1- W+ Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ZArea Pit r Grout Inspection by _ Dat Finaljnspection b Date .r+ Additional Comments: Ap 1 cant - Return all copies to: San Joaquin County Public Health Services �j ou—jr jam' Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CL&O I RECEIVED BY DATE PERMIT'NO. � )i INFO /� CASH stn /h� . EH13.24(REV.��A5) wPIS00 $/.A," EH 14.28