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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOA 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/T,�-, X' J-�7' *a 0 __ City --Z—Cr)-o I Lot Size/Acreage Owner's Name �/r � �-��/ Address _.____—__ Phone �'l�y✓7 Contractori-j C._ Address �!T t _ License No. C Z-Z_ Phone ��93� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT rl DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER Ll Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLU.-- PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (.l Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation _ Dia. of Well Casing _ I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing______ Specifications I'I Public 1-1 Other 1-1 Delta Depth of Grout Seal Type of Grout I I IrriUation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H P. —_— State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION 1 I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial I/Other O--�• , Number of living units: Number of.bedrooms _ 11 Character of soil to a depth of 3 feet: _s1rJ_AX� - Water table depth n�4' SEPTIC TANK Type/Mfg Capacity-�GjLyTi No. Compartments Z PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well�t)P;1 Foundation a- Property Line LEACHING LINE LI-'No. 6 Length of lines _ Total length/size— FILTER BED Cl Distance to nearest: well.1_LU� Foundation - t Property line , SEEPAGE PITS I�CDepth �ol Si:e ._s rw�Lt "�S rL r �_ Number r SUMPS lla— Distance to nearest: Well 2-2-0 Foundation /d7J-1 Property Line DISPOSAL PONDS ❑ 1 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 workmen'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 ire inspections. Complete drawing on reverse side. may/ Signed X Title: Ct.U,V/i( J Date: FOR DEPARTMENT USE ONLY Q I A Iication Accepted by _ Date v h _-- Area Pit r Grout Inspection by "Date��inal Inspection by � Date��Z Additional Comments. Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO E AMOUNT DUE AMOUNT REMITTED CASH d RECEIVED BY {) DATE S] PERMIT NO. • EH 1,.�1REV.rin51 / 1� I I ( it7 c,� I lb J jV-� I � ! �•'. Z/ 1