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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 Regulations of San Joaquin County Public Health Services. ��rr11 Job Address t City ;441 Lot Size/Acreage 1 V� Owner's , Name 15;, 5;G_60hdnJAkd&n �� r� Phone Contractor Address License No, —Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER D Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS /t INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fVY!! n Industrial ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications FI Public f_1 Other ❑ Delta Depth of Grout Seal Type of Grout I t I Irrigation �.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction Well Diameter �f� sealing Utaterial & Depth rr?t4 _ t Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAiR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is r Installation will serve: Residence— Commercial_„__• Other available within 200 leet.t Number of living units: - Numbei'of'bedrooms' Character of soil to a depth of 3 feet: Water table depth i SEPTIC TANK ❑ Type/Mfg Capacity No. pe a II PKG, TREATMENT PLT. 0 � Method of Disposal r` p 4 Distance to nearest: Well Foun Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. all Foundation Property Line SEEPAGE PITS � TM 1I 1'`; Depth Size Number SUMPS . }L • ante to nearest: Well 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-follo nQi."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 Cal' r The applican or all nspections. Complete drawing on revers side. Signed Title: Date: FOR DEPARTMENT USE ONLY Application Accepted byDate z res Pit or Grout Inspection by Date Final Inspection by Date livjaAdditional Comments: IV At ,Atll - Applicant - Return all copies to: San Joaquin County Public Health ServicesC Ws og Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201r_ vL,r,' „f I/ FEE INFO AMOUNT DUE AMOUNT AMOUNT REMITTEp CASH RECEIVED BY DATE PERMIT N0. . EH 13.24 iREV.unfit (y v I� EH 14'26 a ' t Y/ 2