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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 is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and t e Rules and Regulations of San Joaquin County Public Health Services. � Qd D uo gyp_ AAA Job Address 77 Tt,4 / Cit of Size/Acreage a�6 Owner's Name f/»1JyAddress PC arc i3 A '7 L Phone A 7 A 0 F t 7 y Contractor Address � ` License No./�G��+`,�Phone Jfoyi TYPE OF WEL /PU P: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Nell ❑ AAA PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I"I Public ❑ Other fT Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. • State Work Done_ Well Destrucffon ❑ Well Diameter Sealing Material L Depth O Depth Filler Material 1. Depth ` TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is V11 I available within 200 feet.) V Installation will serve: Residence_ Commerciale Number of living units: _ Number of bedrooms Character of wit to a depth of 3 feet: Water table depth _ SEPTIC TANK ❑ Type/Mfg Capacity M No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well10� FJ s Foundation Property Lina LEACHING LINE ❑ No. b Length of lines OL U D Total length/size d �yAr ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line g g SEEPAGE PITS I IDepth a S - Size Number' SUMPS -Cf/Distance to nearest: Well JE Foundation 70 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 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 cenify 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 to a Inspections. CC plate drawing on reverse side. Signed X� �i �?'Yydtif.X Title: n Date: / _ FOR DEPARTMENT USE ONLY ion A copied by r Date �7� Area _ P or rout 41tion by at Final Inspection byT�"�� 4a Date r / ^M r N . Additional Comments: f Q1 Applicant - Return all copies to: San Joaquin County Publ c Health Services — Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK 0 RECEIVED BY DATE PERMITNO. INFO ,ry ,v— / �r 'LL-Z-1 � . EH 14.211 V.rix 41 I /' e y• ./ 1� /I L '� EH t4-7a 111