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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED � (Complete in Triplicate) Application is hereby rade 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 1 62 and the Rules and Regulations of San Joaquin County Public Health Services. Jab Address O City ! Lot Size/Acreage P �+ Owner's Nam L/ /c Phone e C �Ll Address .,.— �-- 10 Contracto 1A, ( Address License No. phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well LI PUMP INSTALLATION ❑ SYSTEM REPAIR ' OTHER ❑ Monitoring Well C7 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 n Industrial 11 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i komestic/Private ❑ Gravel Pack* ❑ Tracy Type of Casing_ Specifications \ V1 Public 1-3 Other n Delta Depth of Grout Seal Type of Grout \ I I Irrigation —.Approx. Depth 4 Eastern Surface Seal Installed by Repair Work Done ,t0c Type of Pump H.P. 2 State Work Done Well Destruction El Well Diameter Sealing Material & Depth f r 5. I , Fi11er Material & Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is �1\ 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 ❑ Type/Mfg W Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal \ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.4 Length of lines Total length/size FILTER BED [_I Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size } Number SUMPS LI Distance to nearest: Well f Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 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 sppli us all for all req inspections. Complete drawing on re at side. " X3 Signed Title: Date: Z=. TMENT USE ONLYApplication Accepted byADate ' L Area��'_4_�— Pit or Grout Inspection by n Date Final Inspection by Date 1 1 r 2— Additional Comments: )�� Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services \ 445 N San Joaquin, P OrBox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED / CK RECEIVED BY ATE PERMIT'NO. � INFO f EH 13.241 REV.lie 5) I ca lEH 11.2E 1"' _ ' •t- 4