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f 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 Z 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 1$62 and the Rules and Regulations of San Joaquin County Public Health services. ` r Lot Size/Acreage Job Address �o r `� i� ° ._ City Owner's Name - �£ ALiJrES E V— Address �3� b s ' � _y � Phone t`3 Contractor � Address ✓� License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ -.WELL REPLACEMENT D DESTRUCTION Gl Out of service Well Well ❑ PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _— INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom 11 Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done C7 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth t � Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 1.1 DESTRUCTION 1.1•INo septic system permitted it public sewer is. available within 200 feet.l Installation will serve: Residence Commercial— Other Number of livi units: Number of bedrooms Character of soil to a 3 feet: Water to lFtr�� SEPTIC TANK ❑ Type/ Capacity No. Compartments PKG. TREATMENT PLT. Cl 4 ` Method at Disposal Distance to nearest: W Foundation Property Line lin th/size LEACHING LINE Cl No. gth of es FILTER BED istance to nearest: . Wall Foundation Props i SEEPAGE PITS 1 I Depth Size Number I SUMPS Ll Distance to nearest: ` Well Foundation Property Line 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 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 applicaust cast for all required ins tions. Complete drawing on reverse side. Signed Title: Date: fOR DEPARTMENT USE ONLY Application Accepted by Date 0 Area ` 1 Pis or Grout inspection by Date .Final Inspection.by Date Additional Comments: Applicant - 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 DtJE' AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'1 D0 INFO r . EN 17.241 REV.1/n5Y ;y i t 9tqZ"J�2 I EH 11-2a r