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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 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.p Job Address � f 4 City I Lot Size/Acreage e / Owner's Name ZGS Addresses 6�_ Phone Contractor ��/ 4sa --_ Address License Na--ZO Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT fl DESTRUCTION ❑ Out of Service we11. ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Velli DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION c AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE Of WELL `PROBLEM AREA CONSTRUCTION SPECIFICATIONS 111 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C7 Domestic/Private ❑ Gravel Pack '❑ Tracy Type oGCasing_ s Specifications \� Il Public fa Other w❑ Delta Depth of Grout Seal j ' Type of Grout v I I Irrigation —.Approx. Depth 11 Eastern Surface Seal Installed by ' Repair Work pone 0-:_•Type of Pump +. H.P. State Work Done ' '" i r 1 Well Destruction ❑� Well piameter. --I Sealing Material Depth i "I Depth t Filler Material S Depth j TYPE OF SEPTIC WORK: NEW.INSTALLATIONfi� REPAIR/ADDITION 1 1 DESTRUCTION I I' (No septic system permitted if public sewer is:, 4 available within 200 feet.) Installation will serve:<y Residence Commercial Other y Number oi,kving units:--4— Number of bedrooms ,.Character of-soil to a-depth of 3 feet: I Water table depth 9 5ER IjC TANK r "O Type/Mfg f� s�-� __ Capacityl Q No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal r Dlstance`t0 nearest: Wel! ZF Foundation ,L� Property Lina ! LEACHING LINE i LVj�=No. 8 Length.of lines -g 4eb Total length/size I r' FILTER BED ! ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ' 11 DepthrC6'__ 7 _Size Number- „ SUMPS LI Distance fo nearest:`; Wellound on Property Line DISPOSAL PONDS 0 r ` I hereby certify that I have prepared this application.and that the workiwill 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, 1 shall employ persons subject to workman's cornpensa- tion laws of California." The applicant must call for at uired Clio Complete drawing on reverse side. / c Signed °- Title: S --- _ Data: I FOR DEPARTMENT USE ONLY . � s Application Accepted by t Date I --9 Z_ Area T Z t r Pit or Grout Inspection by Gate Final Inspection by Date r I. Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, Box 2009, Stkn, CA 95201 F -_- _ -..F E T-F AMOUNT Dt1E-"-" --AMOUNT REMITTED' "CK- _ ECEf1% L) Bt/' D E - PERMIT:NO;T 4 IN . EHI 3-24 iREV. S EH 14.26 /'� ,