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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES L 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 1$62 and the Rules and Regulations of San Joaquin County Pub11c3� th�rvicee. ^ Job Address _—__ Il CC 33`ieE��E� City creag :Lot Size/ 191Jp a� Owner's Name GkrW "I -` �- Address To kA OX,s p ¢'laCr C^ / ��p hone Contractor I&N8 7 Address_9_�VAC b 7. )-41 ��i'.s �_ License No. Phone TYPE'OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 Cl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public Cl 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 ❑ Well Diameter Sealing Material & Depth \ Depth Filler Material b Depth D TYPE.OF 5EPT1C WORK: N V7+ ION I 1 REPAIRJADDITION I I DESTRUCTION 11-(No-septic system permitted if public sewer is available within 200 IeeL l Installation will serve: Residence Commercial_ Other Number of living units: --I— Number of bedrooms 13 // __ r Character of soil to a depth of 3 feet: 2-00/4 _Water table depth SEPTIC TANK 11K Type/Mfg _aMj't`;�, Capacity r„ _1 d No. Compartments �. PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line 6:1� t LEACHING LINE 9( No. & Length of lines Total length/size --Vol i FILTER BED ❑ Distance to nearest: Well Foundation _ /04- Property Line SEEPAGE PITS IVI"' Depth gj4ff Size Number SUMPS LI Distance to nearest: Well_ f4 - Foundation Property Line 54- DISPOSAL PONDS ❑ A 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 canify 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 cartifies 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 mu call for all required inspections. Complete drawing on reverse side. p Signed X Title: a Date: FOR DEPARTMENT USE ONLY Application Accepted by Datef'' 2 �_� �� ?� Area Pit or Grout Inspection by Date Final Inspection by Additional Comments Applicant - Return all copies to: San Joaquin County Public Health Services ' Environmental Health Permit/Services 445 N San Joaquin, Bax 2009, Stkn, CA 95201 FE INFO AMOUNT DUE AMOUNT REMITTEDo CAS KN RECEIVED BY ATE PER MIT'Np. . EM 73.24 IREV.,)Ks) a EH ii•7D