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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 1662 and the Rules and Regulations of San i Joaquin County Public Health Services. Job Address 250_7 3 � C�"""� �' City Lot Size/Acreage J5 0-7 IV. P fe4l &7- 25- cr7 Owner's Name de_t J .eo_"1�T d Lel Address hone ` �' rci• t-� �C�� License No, _✓ zt__7& Phone " l0 5 Contractonl Address TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 1`OTHER ❑ Monitoring Well DISTANCE TO NEAflEST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C) Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Wel! Casing CJ Domestic/Private Ci Gravel Pack ❑ Tracy Type of Casing_ Specifications I"I Public 17 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 0 Type of Pump H.P, r oState Work Dore I Well Destruction ❑ Well Diameter Sealing Material & Depth O Depth Filler Material rF Depth *` TYPE OF SEPTIC WORK: NEW INSTALLATION # I PAI E /ADDITION DESTRUCTION 11JNo.septic.system permitted i1 public sewer is available within 200 feet.) Installation will serve: Residence Commercial— ther rT Number of living units: __L Number q. b drooms Character of soil to a depth of 3 feet: f Water table depth Tl SEPTIC TANK Type/Mfg �� - �`_r-- Capacity No. Compartments PKG. TREATMENT PLT. 0 / -Method of'Disposai Distance to nearest: Well `! Foundation' a --- Property Line _ LEACHING UNE Tzf- No. $ Length of lines Z W 4=— Total length/size Y f FILTER BED ❑ Distance to nearest: Well S ® ff- Foundation - Property Line _ SEEPAGE PITS f -6e Depth 19 :�r Size3,(v _— Number SUMPS LI Distance to nearest: Well f 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 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 California." j The applicant must call torA re 'rad insPe.ctions. Complete drawing on reverse side Signed X Title: _ s �' _ Date: FOR DEPARTMENT USE ONLY Application Accepted by _; r —_ Date '�f�� L_3 Area � Grout Inspection by - Final Inspection by Dete Z- r ate --- Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 945 N San Joaquin, P O Box 2009, Stkn, GA 95201 I FEE AMOUNT DUE AMOUNT REMITTED I CK I CASH RECEIVED BY DATE PERMIT'NO. INFO ,, JJ ,p "��/ . £Ht3.24{REV.rixS! fir U V /V V ��.e�JtD EH 142e