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4 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 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 Address Z!Ef_? ` ' City Lot Size/Acreage Owner's Name lt[b`1?2tr Address �� Phone Contractor If' Tk Address "def-'J_0 License NoIZ7S`.S`.5% Phoned-7^� a� ,. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT>Lr__ DESTRUCTION tkr_Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �� r DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ /7 f� Dia. of Well Casing �Qomestic/Private 1W Gravel Pack', ❑ Tracy Type of Casing_ Dec- Specifications ('I Public Cl Other r (� � �Delta Depth of Grout Seal � _LO T pa of Grout. /� - - -- 47l I I Irrigation �;da AppX. Depth I I Eastern Surface Seel Installed by Repair Work Done 0 Type of Pump H,P, State Work Done Well Destruction CW_ Well Diameter Sealing Material & Depth Depth /100�:F Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sewer is available within 200 feet.M r Installation will serve: Residence _ Commercial— Other Number of living units: Number of bedrooms ww Character of soil 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 Cl No. & Length of lines Total length/size' FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number i SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 �. 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 must call for all required inspections. Complete drawing on reverse side. p Signed c Title: f� A,10 Date: _7 716 F R_DEPARTMENT USE ONLY p, a I Application Accepted byLDate 'i 5 ^L Area "^- a Pit o rou spection by ,�fyd D to Z- "na l Inspection by AWV Date Additional Comments: 779 CIt a Applicant - Return all copies to: San Joaquin Coun y Public Health Services �(d U-14 -Z gr ` Environmental Health Permit/Services 11Q&W [3isE JI 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201�� fftAMOUNT DUE t AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. �, CASH EM 17.211REV.+ir I Kms' s EH 11.2E t