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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 in Triplicate) (Complete p 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. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public Health ervices. Odd City Job Address , Lot Size/Acreage Address . ' _ Phone - r. �S ' Owner's Name r r LA ` �C I�7 t1�" 3Zy-'Z Phone 5105 Contract Address _6 License No. TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT E 1 DESTRUCTION ❑ Out of Service Weil 0 REPAIR C7 OTHER p Monitoring Well ❑ PUMP INSTALLATION ■ SYSTEM DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE-OF WELL . PROBLEMAREA _. CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t:i Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications- - — Q! I'I Public Cl Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation — Approx. Depth I l Eastern Surface Seat Installed by Repair Work Done O Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material Depth Depth ller Material S Depth . TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR ADDITION DESTRUCTION I I INo septic system permitted if public sewer is available within 200 teet.I Installation will serve: Residence Commercial_30ther Number of living units: Number of be ooms Character of&oil to a depth of 3 feet: �� _Water table depth SEPTIC TANK 13Type/Mfg Capacity 'N:,No. Compartments PKG. TREATMENT PLT. ❑ w�Method of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE , No. & Length of lines _ `'A 0 Total length/size K 4 FILTER BED ❑ Distance-to nearest: Well '� 'Foundation 9 Property Line 5 SEEPAGE PITS Depth Size ?(9 lJumber SUMPS LI Distance to nearest: Well O©'t Foundation_ �� } Property Line { DISPOSAL PONDS ❑ I hereby certify that I have prepared-Uri application and that the work-Will be dod'e'in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San :loagwn county Home owner or licensed agent's signature cenifies the following; "I certify tKar-irl t4periormance 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: "1 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 call for a uir inspections. Complete drawing on reverse side. (� C� Signed Title: Dater `� `-� r FOR DEPARTMENT USE ONLY Application Accepted by w Dare 2 Z ' Z Area Pit or Grout Inspection by Date Final Inspection by DateZ Additional Comments: Applicant - Return all copies to: San Joaquin Courity'Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 a FEE AMOUNT DUE AMOUNT REMITTEDCK ECEIVED BY D TE PERMIT NO. INFO EK 13.24(REV.1 i w 5) �7 EK 14.26 r r r