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y1G �tJOAQUIN COUNTY PUBLIC HEALTH SERVICES ft , ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 Cep ty1� ��g�l` P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) a Application Is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This 1 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. ` -a= Job Address +3 City 5'r&Ay Lot Size/Acreage Sa K I Owner's Name E A I C AqD4MarU3AZ Address Phone Contractor_ ELA z/17 d Address License No. Phone TYPE OF WELL/PUMP: 4 NEW WELL ❑ _ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE; -FOUNDATION AGRICULTURE WELL- OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F_1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F [I Domestic/Private ❑ Gravel Pack7 11 Tracy Type of.Casing_ Specifications Il Public [I Other Fl Delta' Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P.- _State Work Done_ Welt Destruction O Well Diameter Sealing Material`&Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRlADDITION DESTRUCTION l I (No septic system permitted if public sewer is _ available within 206 feet.) r Installation will serve: Residence_A:!!� Commercial_ Other Number of living units: Number of bedrooms_-___2e Character of soil to a depth of 3 feet: C t A Water table depth SEPTIC TANK ❑ Typo/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: a Well Foundation Property Line LEACHING LINE ffr"'No. & Length of lines �a r` _-_ Total length/size 30 f FILTER BED ❑ Distance to nearest: Welt Sd Foundation �Q t Property Line _ SEEPAGE PITS l I Depth Size Number SUMPS Ve Distance to nearest: Well'4&` Foundation^ ! D` Property Line DISPOSAL PONDS ❑ 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 ,., 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 subcontracting 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 k tion laws of California." i I The applicant must call for all required inspections. Complete drawing on reverse side. G y Signed X C Title: r-- -- Date: ^7•' 2-4—9 Z_ ---OR Df PARTMENT USE ONLY Application Accepted by oats Area 19 . r ut Inspection b � Date Final Inspection by Date 0-16..-- Pit or G a y l� ILI Additional Comment _ Applicant - Ret r all copies, to San Joaquin County Public Aealith/Sery cervices J �� 9 Rot 11 Environmental Health Permit/Services 770�,(�� r 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 I ` IFEf NFO M NT DUE AMOUNT REMITTED CCK4BY ATE PERMIT�NO. + EN 13-24(pEv.rin5) '� 11 EH 1 .26 l/r {