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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 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 ReguJatione of San Joaquin County Public Health Services. �,�t City - 7`7Cn� Lot Size/Acreage Job Address Owner's Name --ALL /�, Address -rnf4f Phone Contractor �4 , W 0 C r Address 7 ,� .+9L� L _—License No. t�r�7L Phone � TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ Monitoring Well PUMP INSTALLATION 0 SYSTEM REPAIR El OTHER ❑ L7 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 f_l Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation Dia. of Well Casing Type of Casing- Specifications f_l Domestic/Private ❑ Gravel Pack 0 Tracy 9 Type of Grout FI Public Cl Other l� Delta Depth of Grout Seal i I Irrigation __..Approx, Depth I I Eastern Surface Seal Installed by I State Work Done Repair Work Done L7 Type of Pump H.P. Sealing Material & Depth Well Destruction ❑ Well Diameter. r Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic systhin m rented if public sewer is avaInstallation will serve: R idence! Commercial_ Other pa 64je,, AIA 7 f Number of living units: Number of bedrooms Character of soil to a depth 3 feet: g1l, A- Water table depth SEPTIC TANK ❑ Type/Mfg PALL Capacity eta No. Compartments 2 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation , ,L— Property Line '51.4 LEACHING LINE No. & Length of lines ` Total length/size Q_ FILTER BED ❑ Distance to nearest. _-Welt tyA Foundation /d - _ Property Line-' s- � SEEPAGE PITS I Depth ��r - Sizerr Number 3 — v� k SUMPS CI Distance to nearest: Well v q Foundation ZV Ptope(ty Line DISPOSAL PONDS ❑ I hereby certify that t 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 ued, I shall not Home owner or licensed agent's signature certifies the following: "I certify that in-fhe performance of the work for which this permit is iss 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 compense- tion laws of California." The applicant must tail for all required inspectiions. Complete drawing on-reverse slide. Signed X } (,!J> _ Title: ��';^ f Date: �' Z �� - � ~ F FOR DEPARTMENT USE ONLY Q� Application Accepted by u Date`[-� Area Pit or Grout Inspection by Date Final Inspection by Date I 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 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO . £H 13-24 IREY.i i n sl SN EH 14.26