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i 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 Regulations of San I Joaquin County Public Health Services. Job Address h h>�41� City G Lot Size/Acreage p I Owner's Name 0V4CQ 44MA&E—Z Address 2&]k kn�aA Phone . Contractor 006 Z42 jca:74z6k. Address `1ICDf !"Pic) sA26W License No. Phone I TYPE OF WELL/PUMP', NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ - SYSTEM REPAIR C] OTHER ❑ ' Monitoring well C7 DISTANCE TO NEAREST: SEPTIC TANK`S SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AkA CONSTRUCTION SPECIFICATIONS r CI Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack* ❑ Tracy Type of Casing- Specifications ? I'1 Public I:l Other n Delta Depth of Grout Seal Type of Grout I 1 Irrigation —Approx. Depth 11 Eastern Surface Seal Installed by 03 Repair Work Done U Type of Pump - -xH:P' State Work Done Well Destruction ❑ Well Diameter '` -..w-Sealing Material & Depth Depth > +' Filler;Material & Depth A TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR IADDITIONK DESTRUCTION I I (No septic system permitted if public sewer is iv available within 200 feet:) Installation will serve: Residences! Commercial— Other Number of living units: AL Number of bedrooms_b. r Character of will to a depth of 3 feet: _.___ Ah n &L Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well r' Foundation Property Line tl. LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED € ❑ Distance to nearest: Well-..-Foundation Property.Line } SEEPAGE PITS 11 Depth Size umber __ SUMPS � Distance to nearest: Well Foundation Jf � 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 Iowa of California." The applicant must call fc II re red ins ctions. Complete drawing on reverse side. . Signed X Title: —. _ �� Date: r- I FOR DEPARTMENT USE ONLY i Application Accepted by _ Date L Area �! Pit or Grout Inspection by Date Final Inspection by Oate-J �Z f� Additional Comments: Applicant - Return all copies to: San Joaquin County Public health Services 1 Environmental Health Permit/Services ' +dq ► 445 N San Joaquin, P 0 Box 2009, Stkn,(CA 95201 I .NFD AMOUNT DUE AMOUNT REMITTEDCK w. RECEIVED BY DATE Pt3RMI7"NO. . EH 13-24(REV.1'.., / !/ 2- �[I EH 1446