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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -, � ENVIRONMENTAL HEALTH DIVISION scANNED 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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. Job Address "13 City Sne' Lot Size/Acreage 16Sga 4d 1, Owner's Name F. FIEd-PS Address _ &A4EZ✓=M2AZ 13E84QV, 114 92-649 Phone 4,& Contractors Ll.-igz0 Address 74/.AD_-z_dZ 7- Au'E License No. 4ZfL7Z Phone �r 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FI DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 P Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications I"I Public (:1 Other F] Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I 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 I I REPAIR/ADDITION X DESTRUCTION I I INo septic system permitted if public sewer is J available within 200 feet.) Installation will serve: Residence— Commercial_ Other M PA,eA Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: CLAD Water table depth SEPTIC TANK O Type/Mfg XLa-r,AJ6 Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Its No. & Length of lines _J'-lee, ' Total length/size lees' FILTER BED ❑ Distance to nearest: Well Je2e`�- Foundation Sc7 ' Property Line 1� SEEPAGE PITS Depth a5' Size�i�? _ Number SUMPS LI Distance to nearest: Well ZOO f- Foundation /2-2 f" Property Line 710/* DISPOSAL PONDS O 1 hereby certify that f 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 must call for all required inspections. Complete drawing onreverse _side. Signed X GljJ tNo Title: �Ln� Date: FO ARTM NT USE ONLY A plication Accepted by Dat / ea � 7 Pit Grout Inspection by Date Final Inspection y Date C dditional 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 AMOUNTREMITTED INFO CASH RECEIVED BY DATE PERMIT NO. . EH 13.21 1REV,i i x si EH 14.25