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t f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 PEP O BOX 2009, STOCKTON, CA 95201 RMIT 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 .thth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �-� �A. Ab City S7kx/ Lot Size/Acreage Owner's Name T10 AIA f,9 —a�FlL�- Address '�"'�� Phone X31 O Contractor �l4 d �--- Address License No. 46 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION L1 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl 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 Ll Industrial ❑ Open Bottom' ❑ Manteca Dia. of Well Excavation _—Dia. of Well Casing C] DomesticlPrivate ❑ Gravel PackL1 Tracy Type of Casing_ Specifications F I'! Public I:1 Other .11 n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I ) Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth ) Filler Material & Depth P TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 ,DESTRUCTION I i INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence�i Commercial _ Other L&I 7-079= P��►13� ; Number of living units: _I— Number of bedrooms -± pp,,_ie/a Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK. O Type/Mfg r1 �9�L __ Capacity L Z� No. Compartments 2— PKG. TREATMENT PLT., 0 Method_of Disposal —Distance to nearest: Well -3 Foundation 7421 Property Line _ LEACHING LINE M--;No.. Length of lines g-� Total length/size e FILTER BED ❑ Distance to nearest: Well .P'f Foundations" '3O ` _ Property Line SEEPAGE PITS Depth Size [[' Number SUMPS LI Distance to nearest: Well " ` Foundation /ZO Property Line DISPOSAL PONDS ❑ I 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 Home owner or licensed agent's signature'cenifies 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.16 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 empl6y persons subject to workman's compensa- tion laws of California." �. i The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: _ Date: Z� I i <yOEt DEPARTMENT USE ONLY -712 GG Appfication Accepted by Date D �� Area I Pit or Grout Inspection by Date Final Inspection by Data 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 ASH CK RECEIVED BY DATE PERMIT'NO. IN FC� EH13.24(REV.t/Ksi ll7 k ._ ? EH 14.26