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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 { PERMIT EXPIRES 1 YEAR FROM DATE ISSUID (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. Job Address =e�. —gl,(, E,LLS7`A�� City l LottSize/Acreage f/ (1Q t� Owner's Name l L7 �� I�� ( Address �� Phone Contractor , t ta Thr"Address 7 f7'brL✓. /�/e�CSS Lrinse Nr*- f� � Phon 2 /�/ y TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLA��TII,ON,,��❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK LJ[' SEWER LINES /lam / DISPOSAL FLD. PROP. LINE FOUNDATION ` AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationDia. of Well Casing [:I Domest4c/Private Gravel Pack ❑ Tracy Type of Casing_ r'V 6, Specifications I') Publio f-I Othe n Delta Depth of Grout Seal _ �o Type of Grout (�4-krioation �. Depth I I Eastern Sprface Seal 1pstalled by/tuSCf�ic Repair Work Done U Type of Pump H.P. State Work Done_ e" Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 111No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other ip 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 k Distance to nearest; Well Foundation �_ Property Line i • a LEACHING LINE ❑ No. &1engtlrof lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 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 applicantmut t call for all required ins c'ons. Complete drawing on reverse side. /� 'rSigned X !/ 1 OL YG2:[�4�.+. Title: La L .Lyl Date: FOR DEPARTMENT USE ONLY �f d Application Accepted byAwl Date f` Area Pit¢ -. ut I eAF 4F r Grospection b Date/. ►.Final Inspection by Date Additional Comments: . 10di lceftk A I i • A04 0040F." t a - 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 RECEIVED BY DATE PERMIT'NO. INFO + EH13-24(REV.I/x s) yd Pip • EH 14-26 / � (/ !