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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 EgPIRES 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 Se -ices. �S � Job Address CJ d �_ City � Lot Size/Acreage I Owner's Name `� Address PhU one " � z7 Cornlrat:1 .G a, Address �* L f License No. c�7� C'Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 171 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C3Monitoring Well C� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL ___ =_,OTHER WELL PETS/SUMPS INTENDED USE TYPE OF WELL yPROBLEM AREA CONSTRUCT40N SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca t Dia. of Well Excavation pia. of Well Casing El Domestic/Private ❑ Gravel Pack7 L3 Tracy r Type of Casing_ Specifications A VI Public CI Other , n Delta .Depth of Grout Seal Type of Grout I i Irrigation Approx. Depth [ I Eastern Surface Seal Installed by d Repair Work Done L7 Type..of.Pump_ -H'P. State•NVork Done Weft Destruction O Wall Diameter Sealing Material & Depth '� 1 rDepth Filler Material & Depth TYPE OF"SEPTIC WORK:INEW INSTALLATION REPAIR/ADDITION'( F DESTRUCTION l I (No septic system permitted if pt biic sewer is available within 200 feet.) Installation will serve: Residence []�... Commercial_ ther Number of living units: i �� Number of bedr oms � _� —w•. Character of soil to a depth of 3 feet: Water table depth JO f v 1 SEPTIC TANK. �Type/Mfg Capacity � Na. Compartments PKG. TREATMENT PLT. Cl / / Method of Disgosal Distance to neirest: Well 150k Foundation Property Line! 1 � / LEACHING LINE Y✓ No. & Length of lines G Total length/size FILTER BED /❑` Distance to nearest: Well � AJC ' s�' 1 Foundation property Line SEEPAGE PITS 5_4 Depth CV —Size614Number SUMPS LI Distance to nearest: Well Foundation ''f DISPOSAL PONDS ❑ # _ Property Line_ 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 Homeowner 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 laws of California." The applies st call f re ired inspections. Complete drawing on reverse mid ,, Signed Title: / Date: F FOR DEPARTMENT USE ONLY JC2�1 Application Accepted by Date Area t0or Grout Inspection byDate rO' Final inspection by J Date �2 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N�ioaquin, oar 2009, Stkn, GA 95201 FEE AMOUNT DUE AMOUNT RI CEIVE BY D E PERMIT Np. IN . E 13-2 IREV.Iin5 EH 1C26