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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 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 In made in compliance with San Joaquin County Ordinance No. 5ti9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address L o �� d City Lot Size/Acreage r Owner's Name f.l� e ka �,jg; r c:6 ,f /— u te A Phone Contractor�� M Address r.l t� c �Q' License No �Phnne3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL FIEPLACEMENT>< DESTRUCTION XOut of Service Well ❑ -PUMP-INSTALLAT10N,>f- SYSTEM REPAIR 0 OTHER ❑ Monitoring Well n DISTANCE TO NEAREST: SEPTIC TANK �0/ SEWER LINES DISPOSAL FLD. PROP. LINE 1A FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , n industrial °Open Bottom ❑ Manteca Dia. of Well Excavation J=2 Dia. of Well Casing XDomestic/Private ❑ Gravel Pack Ll Tracy Type of Casing_:Z�-_1 Specifications 1'1 Public El Other n Delta Depth of Grout Seal 0 r T e oi.Gr t � t I # Irrigation cAWApprox. Depth I i Eastern Surface Seal Installed by / A >Al% IZI flc_rt e. _ Repair Work Done 0 Type of Pump _ H.P. State Work Done I Destruction � Well Diameter l Q,� Seaming Material aE Depth �7 �V�1C/ Depth ,�I�'!`) � Filler Material d, Depth �� (�u,c zn �ytla �l]�dN�' P TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION l 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 . ,l SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line 0 LEACHING LINE ❑ No. & Length of tines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 0 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 re�ed�pectrons. Complete drawing on reverse side. Signed x �f �l 49A AX.�{� Title: - Date: /� Y� OR DEPARTMENT USE ONLY Z Application Accepted by 01 a.,�A Date ._ �'`a- i"�Z____ Areal 62 Pit or ,Out Inspection by,� Date Q-� 2 Final Inspection by_T�PSV_"�L Wit__ Date.,,t�2_q_�_ 'Z_ 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 WR NFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED SY DATE PERMITNO. . EN13.241AEV.v/MSl W� 1 rQ� 9-- 14?q H 14.2e 444 1 1'�G2�40 I • I ,