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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION A 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 , PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Ilan 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. U /] Job Address dO V1_�67 City Lot Size/Acreage Owner's Name r8 1/Z 2- ZC�'�;44z�. Address/4Z A/.4.s�',�� i:� Phone '7 I/ ,.4lsfS`6 /YZf✓`y � 4, ContractorC:1/7 � /� !'?7C Address License fVv. -!r 4 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION Out of Service Well C1 PUMP INSTALLATION C7 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well r� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 1 DISPOSAL fLD. PROP. Ll FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED"USE " ' -TYPE OF WELL PROBLEMAREA-,—CONSTRUCTION SPECIFICATIONS Y�•�--- rr"� I t L-] Industrial ❑ Open Bottom L7 Manteca `- Dia. of Well Excavation ' Dia. of Well Casing E) Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing_ Specifications J i'I Public EI Other n Delta Depth of Grout Seal Type of Grout ! I i Irrigation Approx. Depth l I Eastern Surface Seal Installed Repair Work Done U Type of Pump H.P. State Work Dona - ► — Sealing Material & Depth Well estru tion � Well Diameter �� f �2/ Depth Filler Material & Depth r } Jl ,� . -1 � TYPE OF SEPTIC WORK: JNEW INSTALLATION I 1 REPAIR/ADDITION I k DESTRUCTION i I -INo septic system permitted if public sewer isbo 4o lei available within 200 feet.) Installation will serve: Residence— Commercial_ Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑: Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/site - A FILTER BED n Distance to nearest: Well Foundation Property Line ✓+ SEEPAGE PITS 1 1. Depth Sire Number SUMPS LI, 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 isissued,^[.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 ust cal for all r 'rad i o.clions. Complete drawing on averse side, k ♦: - Signed '� -• ,,.. Titled %mac- Gfa "� Date: — 4 i, FOR DE RTMENT USE ONLY ` !/V Application Accepted by Date a �! Pit or Grout Inspection by w Date Final Inspection Date�� =Z'%. k Additional 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 95201FEE ` r ' INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT'NO. { EM 13-24 114EV,$1 h 5) , EH 14.20 i r /Jn r tY LC]6 i