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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION cf 445 N SAN JOAQUIN, PHONE (209)468-3420 _A •�` P 0 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. AA Job Address 3 1 / s' R Z� rd/-r -J T City Size/Acreage l-0 A-C-r'U* Owner's Name ✓s+��'�" r�,M eff iL Address 5704_'`- -91 _ Phone Contractor �Li� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 n Industrial, ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Orivate ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications ( ` - I'l Public (1 Other n Delta Depth of Grout Seal Type of Grout \\' I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence e Commercial-cher Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Q Q � Water table depth Z0 SEPTIC TANK W Type/Mfg L c Capacity/- 1400 No. Compartments PKG. TREATMENT PLT. ❑ t �" lZ �U Method of Disposal L`4 Lt r Distance to nearest: Well Foundations Property Line LEACHING LINE fkl�No. & Length of lines �L_4��ou�ndation�- � ength/sizeFILTER B D ❑ Distance to nearest: WellPropertyLine s, L J H{ 1f Ve- eX SEEPAGE PITS I I Depth 3� Sizel �� l��;'o Number !!2 9;4 SUMPS JDistance to nearest: Well/ '� F�n s � Property e < r DISPOSAL PONDS O 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 thefollor w' : "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 Cal' a. The applicant " ca or all ui d inspe, tons. Complete drawing o verse ide. Q Signed X A , Title: Date: R DEP TMENT SE ONLY Application Accepted by Date Pit or Grout Inspection by Date Final Inspection � Dat Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin,-J2_0 Box 2009, Stkn, CA 95201 /IN�(/E AMOUNT DUE /AMOUNT REMITTED CK CEIVED BY ATE PERMIT'NO. . FO EH 13-26(REV.I/H 51 `-�{�. , 00 {/ , EH 142e aJ1 _ !!!