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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 E%'P:IRES 1. YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County foig a permit to construct and/or install the work herein'described. This application is made in compliance with San Joaquin G6unty Ordinance 2. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. p , #) �}- -1 IN , ~r� `� / +1 p City Lot Size/Acreage -1 f 'r Job Addresd /! '' f :.: 01^ Address ;,-�� Phone Owners Name Contractor_ Address' Lioense No. _ Phone' TYPE OF WELL/ NEW WELL❑ "" ° 'WELL REPLACEMENT'll "` Z7ESTRUCTION ❑ Out Mf,service well onitoring well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O 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 I D Industrial ❑ Open Bottom C7 Manteca Dia. of Well Excavation Dia. of Well Casing C] Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing_ Specifications I'I Public i-1 Other P Delta Depth of Grout Seal Type of Grout �]�l 1 .. 1.1 Irrigation Approx. Depth ;1.1 Easternt,,; _' Surface Seal installed by 'Repair Work Done ❑ Type of Pump H.P - State Work-Done , Sealing Naterial & Depth..' } Well Destruction ❑ Well Diameter ,- Depth Filler Material i Depth To TYPE OF SEPTIC WORK; NEW INSTALLATION I i REPAIRIADDITION i DESTRUCTION I i iNo septic system permitted if public sewer is _-_ .available within 200 leer.t Installation will serve: Residence'f�Commercial— ther d Number of living units: Number.at ooms Character of soif'to a depth of 3,fest: .� �.t�tYlsr�r `B Water tabte.depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal p Distance to nearest: Well Foundatiori- �- Property Line !' LEACHING LINE 0 No. & Length of lines Tral length/size FILTER BED BEY Distance to nearest. Well.�+ Foundation 'd Property,Line SEEPAGE PITS I I Depth Size Number �e. :SUMPS LI Distance to nearest: Well Foundation Property Line i 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 Cafifornla." The applicant must call for all required inGpgr ions. Complete drawing on reverse side. Signed X. / rl .: -fr >�.i- �h"':4 Title: .y- t- Date: _ DEPA U OfVLY•+ p� r pJ/4 w Application.Accepted by" 44 Date Area Pit or Grout Inspection by Date r' Finial Inspection by Date/ - Additional Comments: Y +T y Applicant - Return all copies to: San Joaquin County Public Health Services E6vironmental Health Permit/Services p i 445=N-San-Joaquin,—P O•Box.2009-,-Stkn-,'CA 95201 FEE MOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT"NO. INFO . EH 17.24 IREV.r i x 51 - /fes/, p ® �Oea 6�- _ xg 'EH 1146 ��