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Il _ ` SAN JOA UIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 �I PERMIT EXPIRES 1 YF AH FROM DATE ISSUED (Complete in Triplicate) i 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Pv1+1';c,Heap►• 7 ••vices.., Job Address °) � .�;.� � City 7700 Lot Size/Acreage e Y ...� it qj all 6, Owner's Name M Address (l N�/Lffzr(iso Phone /G Contractor Address License No. Phone ' TYPE OF WELL/PUMP:h NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well II PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ Monitoring Well C7 i DISTANCE TO NEARESt: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE II FOUNDATION AGRICULTURE WELL ' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 3 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing , D Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public [I Other n Delta Depth of Grout Seat Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ 1 Well Destruction ❑ Well Diameter Sealing flaterial i Depth �^ a i. Depth Filler Materiel B Depth. TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I- 1No septic system permitted if public sewer is ,f { available within 200 feet.) Installation wdl serve: I�Residence_ Commercial_ Other Number of living units: Number of bedrooms 1 f Character of soar 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 LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED ��❑ Distance to nearest. Well Foundation Property Lina II ' SEEPAGE PITS t I Depth Size Number SUMPS I Ll Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS I ❑ 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, an rules and regulations of the San Joaquin County Home owner or licensed jagent's iignature 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 lawi of Caiifdrnii."Contractor's hiring or sub-contracting signature certifies the faeowing: "I'' rtify that in the performance of the work for which this permit is issued, I shall employ persons subject.to workman's compensa- tion pvvs of lifornla."I, a The applics t call r r i i ions. C Ole a drawing on reverse side. 1 XS Title: flCa/n/ _. Date: � II FOR DEPARTMENT USE ONLY Application Accepted by kb Dat s q Area o�t� Pit or Grout Inspection by Date Final Inspection by Date / Additional Comments: �� v a It �i. GF Applicant - Return all copi&to: lSanJoaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IFEE NFO I1AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EN1374 INEV.I/ti 51 II. Q` (J(� 7i1 I J• ��' EN 114.7e