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t� V_ V SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ` 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O9 77-c—+� �� .S-T (Complete in Triplicate) 0(o — 0&0-0 f 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`l,&p Health Services. ��1� S7 Job Address t=QUE R KCTTLEMA4J ,W 0 S�f�'` CitY L_0D1 _ Lot Size/Acreage // I Owner's Name G l i Lo t n F 0 1 A[d_drre_,sss CR Phone ContractorNAddress - ; License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ , WELL REPLACEMENT E-1 DESTRUCTION Cl Out of Service Well Cl PUMP INSTALLATION O SYSTEM REPAIR A 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 * industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing * Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing._ Specifications t Public C1 Other n 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. Lo 'State Work Done T +Qar'V Depth l & D i t M Sealing Material ep4- Well Destruction ❑ Well Diameter Seal ��LQ DepthFiller Material & Depth - 4 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION E I DESTRUCTION I I (No 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: Water table depth SEPTIC TANK. 0-.Type/.Mfg Capacity No..Compartments Q PKG. TREATMENT PLT. CI Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well r Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation 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 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 applicant mus II far all zir ad ins ctions. Com to drawing on r se sr Signed X Title: � � Nroc GNU Date: 7-0.54.—ft FO"EEARTMENT USE ONLY --f Application Accepted by Alt 4A Date t �� Z Area Pit or Grout Inspection by Date Final 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 O Box 2009, Stkn, CA 95201 I lFEE AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED 8Y DATE PERMIT'NO. Ptd tts rf� Ys- J' EH c3-24(REV.r E 4-25 i n si H 1 + f+