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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, Ci 95201 ik PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Tri.plicatl) 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 Ban Joaquin County Ordinance No. 549 ane 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address A'U-eCity ! k Lot Size/Acreage Owner's Name A-f Address e Phone Contractor Address v�D ti l�icense No. �,1)_--Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT"i 1 DESTRUCTIO t of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L7, OTHER Monitoring Well ❑ + DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL-= ITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation `I Diaof Well Casing F C:1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_.- M Specifications t t I'I Public Cl Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Saul Inst ailed by 4 # j Repair Work Done L3Type of Pump H.P. f ' ' f State Work Done _ Material ling ?E Depth i Well Destruction ❑ Well Diameter Sea Depth Filler Material &Depth + I� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION Mo septic system permitted if public sewer is available within 200 feet.l O installation will serve: Residence_ Commercial— Other �• Number of living units: Number of bedrooms ' ..5 44} �. Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK. ❑ Type/Mfg ,Capacity k '�' ` No. Compartments ff PKG. TREATMENT PLT. ❑ Method of Disposal � ti+• � sP tt Distance to nearest: Well—.Foundation - Property Line - d LEACHING LINE ❑ No. & Length of lines Totai length/size FILTER BED n Distance to nearest: Well Foundation '� Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation k 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 h 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 callforall required inspections. Complete drawing on reverse side. Signed X , - f Y��7t'P�_I-- --- --- Title: k Date: OR EPENT USE ONLY I� Application Accepted by aAAA *-- Date (0-1 Area 01+ Pit or Grout Inspection by Date � Final Inspection by Date Additional Comments: tA1[�tA t a t+ f �� py 4?1+" VAApplicant - Return all copies to: San Joaquin County Public Health Service 8 � i � � Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Sikn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH + EH I3-141REV.+/H5i I 65V ilaa / / EH 14.26 /