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SAN .QUIN COUNTY PUBLIC HEALTH ;� VICES `,MVIRONMENTAL HEALTH DIVISIO.o' 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 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. Job Ad�d1ress/v� / ..� J, �' S1ree City S Oe..K/onJ Lot Size/Acreage 0A6' rn:n 9 Y Owner's Name Address 0-7& E4 s t C kA /« W'y Phone'Z� �`�� ?0 01iX 2oy8 siaK-er CA Contractor WQ_� Z S 16f Address P-0 � i ense No. 57 .1(9,9 Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTTIR Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU. -", "PROP b N E 3 nes FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y�� n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [:l Domestic/Private O Gravel Pack ❑ Tracy Type of Casing SCJy,(v14P_ 4/1) PV Specifications Il Public 1:1 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. State Work Done_ 1 Well Destruction O Well Diameter Sealing Material & Depth r Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.O Method of Disposal �` \ Distance to nearest: Well Foundation Property Line LEACHING LINE O No. b Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 muct at all req ad ins ctions Complete drawing on reverse side. Signed X Title: Cf V: / Date:af / TMENT USE ONLY Application Accepted by Date - — 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT•NO. . EN 13.24(REV.I/R5) �Q (�0 � (�0 /J/�� 3 EN 11.20 Fl /� F