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g, 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. 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. /� y�w Job Address / 9 A� City /- Lot Size/Acreage /r C- wn is Name �6�/ ^�G* iE�� e e � i ds'1fPhone ------------- Con�tr'attor ddress � � � f fi� License No. f� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTX_ DESTRU,CTION Out of Service Well 10 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring dell 11 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. f �.-PROP. LINE FOUNDATION AGRICULTURE WELL :S=OTHER WELL /i- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 17, Dia. of.Well Casing �( .Domestic/Private Gravel Pack C] Tracy Type of Casing- `= S/p�ecification -ets f'1 Public fa OtheLj f nDelta Depth of Grout Seal ^PG�) �Type of Grout t I I Irrigation App x. Depth I I Eastern Surface Seal Installed by y Repair Work Done U Type of Pump q H.P.- :77> ' State Work Done }i Well Destruction ❑ Well Diameter, � Sealing late Dept ltc + Filler Material & Depth y TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No 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 U Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal (� Distance to nearest: Well Foundation ' Property Line . f LEACHING LINE CI No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well -Foundation - Propertyno t M t SEEPAGE PITS 11 Depth Size _ Number - _ SUMPS LI Distance to nearest: Well ----Foundation III,Property': Rr DISPOSAL PONDS ❑ I 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 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 applican l 'r II req�ions. te drawing on rev rat sideSigned Xitle: � 'r - Date:- e Application Accepted by s Date �— Area �I Pit orgut nspection byDate - -_FiIhal Inspection byDate17. f � Additional Comments: ? � o _�Ile 0� �.,/�d/G 9� 0Q Applicant Return-all-copies-to:---�San Joaquin-County-Puli1lid"Health Services' Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEAI.NoF/O� AMOUNT DUE AMOUNT REMITTED CK t '`RECEIVED BY DATE PERMiT'NO. t R Cl a ,/ (�137�)� . EH 13.21 1REV.I/x 51 WAV- `Q/� 1 { 1,V O /© 7—a3-7� EH 11•26 / O.