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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION i 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 i 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. 1 a Job Address ry C, ,I /j/ I�7t �✓ City �0C 1 r Lot Size/Acreage ' -per- ? , LC (� LJ ! if�>� dress J�lj U �rd?nl�S �� Phone JJ Owner's Name -•----gam- — ( --' �a Address C � �� License No.�_ Z3 22_phane� � -2.- Contractor 'J''` TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ .PUMP iNST _,ALLA710NT❑ - ,_ SYSTEM REP.,91R._L7y . r QTHER ❑._ _Monitoring Well__ DISTANCE TO NEAREST: SEPTIC TAf K SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS J INTENDED USE TYPE OF WELL PROBLEM,AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ i Specifications F1 Public l-1 Other 11 Delta Depth of Grout Seal I Type of GroutINS I IrrigationApprox; pep h l I Eastern `ti urface Seal Installed by Repair Work Done 54.. Type of Pump U H.P. State Work Done "��fkl � L Well Destruction ❑ Well Diameter Sealing Material & Depth -c. Depth ► Filler Material 3.Depth ' TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I 1`'DESTRUCTION i I lNo septic system permitted if public sewer is available within 200 feet.l installation will serve; Residence— Commercial_ " Other Number of living units: Number of bedrooms`__� � Character of soil to a depth of 3 feet: - 4 Water table depth r SEPTIC TANK ❑ Type/Mfg 'Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation � Property Line LEACHING LINE D No. & Length of lines Total length/size FILTER BED F-1 Distance to nearest; Well Foundation :Property Line I SEEPAGE PITS I'] Depth Size Number. SUMPS L1 Distance to nearest: Well Foundation Property Line i DISPOSAL PONDS ❑ "t I hereby certify that 1 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 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 workmen's compensation laws of California."Contractor's hiring or sub-contracting signature i certifies the following: "I cartify 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 1 c far all re uad inspections. Complete drawing on reverse side. I Signed X• " f �fTitle: l Date: 12- 9 � R DEPARTMENT USE ONLY p Application Accepted by -C4 A Date �` Area r� Pit or Grout Inspection by Date Finer Inspection by Date 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 FEE AMOUNT DUE ANrUNT REMITTED CK RECEIVED BY DyrE PERMI1"N0. INFO Eli 1 •21(REV.1/X 51 Fj F p L7 r EH 74.26 J I