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k y' SAN JOAQUIN COUNTY -PUBLIC HEALTH SERVICES T._ 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) 4 Application is hereby mads 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 1662 and the Rules and Regulations of San Joaquin County Public Health ServiceB. . e ` Z/07P S SeX�ti .tea. ,,E R:W= �// Job Address ./ Cir Lot Size/Acreage Owner's Name yAddress Q/Q72 7WAI 1P_,0- Phone .38 p- 3�4� Contracto /eS7Ze WW[ddress o�DC7 tit cens No. // ��t��O Phon TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP fNSTALLATION SYSTEM REPAIR ❑ OTHER O Monitoring Well I7 DISTANCE TO NEAREST: SEPTIC TANK_�449 SEWER LINES DISPOSAL FLD. 60 'PROP. LINE -.1-1; i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial, O Open Bottom r � ❑ Manteca _ _ . Dia of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack0 Tracy Type of Casing PMZ� _ -_,,�,�� Specifications�49 ZW I'I Public , El Other n Delta Depth of Grout Seal O Type of Grout.�A4yC4C i I Irrigation { _,Approx. Depth t I Eastern Surface Sedi installed by LC Ee Repair Work Done. .0 Type of Pump H.P. State Work Done ~ Well Destruction O Well Diameter ' Sealing Material A Depth + . C? Depth E Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I` DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I Water table depth , SEPTIC TANK ❑ Type IMfg Capacity. 'No. Compartments PKG, TREATMENT PLT. C14 r Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE 0 No. 8 Length 041,16S.— f Total length/size FILTER BED ❑ Distance to nearest: WBII 4Foundation Property Line i SEEPAGE PITS 11 Depih 4 Size _ Number SUMPS I I Distance to nearest. Well Foundation Property Line DISPOSAL PONDS ❑ { iI 1 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 1 rules and regulations of the San Joaquin County Home owner or licensed agent's signature oenifies 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 cenify that in th performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion Ia ornla." r The plicant mu a fo•all ui ctionplete drawing o arse aide. �} Signed �� Title: 7 Z Date: FO DEPARTMENT USE ONLY C� l Application Accepted by Date �`T — as L Pit or Grout Inspection byD to Z Final Inspection by –.4 Date��_ Additional Comments: ` �� Applicant - Return all cops � San Joaquin County Public Health Services ` r Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE C1PEflMIT N0. , . EH 13-24 iREV.r/n si EH 54.26 .3' I f VID 1 i