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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION f9 445 N SAN JOAQUIN, PH6NE (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 �`-' r " "�� ' SGx�LrE City G Lot Size/Acreage Owner's Name FJF2�F r LA&� Z Address -7C1 g SCI- A-72 / Phone 03X- Contractor Address 4C License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well D 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 Welt Casing (7 Domestic/Private Cf Gravel Pack ❑ Tracy Type of Casing— Specifications I'l Public 1'1 Other 171 Delta Depth of Grout Seal Type of Grout I # Irrigation _.Approx. Depth 11 Eastern y ace Seal Installed by Repair Work Done_ 0 Type of Pump d�J , H.P.-�t _ State Work Oone�� A Well Destruction ❑ Well Diameter Sealing Material & Depth &/4el/- Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 31 available within 100 feet.) Installation will serve: Residence_ Commercial_ Other `\ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line n I - L 41 7� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED i_f Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 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 cenifies the following; "I certify that in the performance of the work for which this permit is issued. I shall nor employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature cenifies 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 applica muot call for al a fired inspections. Complete drawing on reverse side. ' Signed X Title: Data: FOR DEPARTMENT USE ONLY Application Accepted by Date I l3 ! Z Area r� Pit or Grout Inspection by Data Final Inspection by Date f 2— Additional —Additional Comments: ! Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 + IFES NFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT NO. I , { EH 17.24fREV.Iin$I ..�E LLS ��4 l r3 ! �L3 q �T f EH tt-26 !! I