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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 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 .��n9�� S0, ' g i 7-4/ IV' City T�Ae,4 Lot Size/Acreage Owner's Name Po v j,3 i S 4e' 'Address 30470? 50 i;rd0 Frei. Phone IF Contractor r* -i 5o/0, Address 460 A, 17 L.✓ ✓�'� License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well Cl 6 PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL_F.LD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 17 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications I'1 Public El Other 171 Delta Depth of Grout Seal Type of Grout 11 Irrigation —.Approx. Depth LI Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. �•' � } ,State Work-Done Seal Material:,& Depth Well Destruction ❑ Well Diameter � s, Depth Filler Material tDepth TYPE OF SEPTIC WORK: NEW INSTALLATION —REPAIR/ADDITION 1 1 DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Cocarwereiel Other I Number of living units: Number of bedrooms Character of soil to s depth of 3 feet: C 4/1 Wa er-table depth 1t (� j SEPTIC TANK ® Type/Mfg 19-f LOTZ' PCL • Capacity 19 oo No. Compartments 11� PKG. TREATMENT PLT. C1 ' i' Method of Disposal Distance to nearest, Well /Q f3 Foundation y Property Line �G _ LEACHING LINE Ll No. & Length of tines /Cd Total length/size 3t7 FILTER BED 1-1 Distance to nearest. Welt �`O Foundation f 4 Property Line G O SEEPAGE PITS 11 Depth Sire -- " R Number f y SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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 0 Home owner or licensed agent's signature certifies the following: "I.certity 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.,r 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." f The applicant mu t call for all required inspections. Complete drawing on'reverse side. Signed = Title: i Date: _- 1 FOR SPAR ENT USE ONLY Application Accepted by Date res Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: i 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 INFO FEE AMOUNT DUE AMOUNT REMITTED C K H RECEIVED BY DATE PERMIT'NO. ' a EMI 1REV.1/w 51 //� yr (� v7-? EH 14.;*