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SAN J"Y%QUIN COUNTY PUBLIC HEALTH SLICES 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 15 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 AddresaJc' /v�ra�4N ,,� v City o0_9LO i Lot Size/Acreage '" , /.3790. Owner's Name l'r1 y_ C�2 ��(� Address Phone 33,/ y3 Contractor /�+� Address �� License No. .`��'S 7.2/ Phone jE�Cl.S'9j TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION O Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing O Domestic/Private O Gravel Pack ❑ Tracy Type of Casing_ Specifications �-c� I'I Public [-IOtherfl Delta Depth of Grout Seal Type of Grout 0Z I I Irrigation —.Approx. Depth 1 I Eastern Surface Seal Installed by z-- Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material L Depth DepthFiller Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is �N`_R�t available within 200 feet.l Installation will serve: Residence_ Commercial Other Number of living units: _ Number of bedrooms Character of sort to a depth of 3 feet: `154iiJkl - Water table depth Sn SEPTIC TANK 9-- Type/Mfg Capacity /&`rco No. Compartments 2-- PKG. PKG. TREATMENT PLT. ❑ _ Method of Disposal Distance to nearest: Well -P- Foundation Property Line /0 r LEACHING LINE Lf-No. 6 Length of lines Total length/size gpB FILTER BED ❑ Distance to.nearest: Well 1.:f C) Foundation /cam ' Property Lino r SEEPAGE PITS Aftepth of - Size Number Z SUMPS lik- Distance to nearest: Well .72-26 Foundation 1d>5 1 Property Line s DISPOSAL PONDS O I hereby cenify 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: "1 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 reiinspections. Complete drawing on reverse side. - Signed X Title: (f [✓.5.altA Date: '� F R DEPARTMENT USE ONLY C� A licabon Accepted by Date v-�-� Z' Area Cp Pit r Grout Inspection by Date&� .Final Inspection by��_ Date �y Additional ComrtwnL: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Boz 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO ('C��Ap�SH ((JJ ( q . EH 13-24 frilly.lin sl �� I EH 1410