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SAN /AQUIN COUNTY PUBLIC HEALTH :RVICES 1-1 ENVIRONMENTAL HEALTH DIVIS�A 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby glade to San Joaquin County for a permit to construct and/or install the work herein described. This application is glade 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 '_TZ Z d Z C - �` "�� ()y A-P City SIX. Lot Size/Acreage q )(Owner's Name 9A U�r 4 gwesC 4 N / Address -Y Z Ic-Z. 'Z 4y�-• _ Phone Contractor MC�.S',(?Ok1T. Address /'0, 4o,k 2? y4- 60E License No. �955' 9 Phone_ -20 q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 'V INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'l Public fl Other F1 Delta Depth of Grout Seal Type of drout rn I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by 1 Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Materiel &-Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if 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: 7 Water table depth f SEPTIC TANK O Type/Ma0ac* No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal Distance to near st. II un to Property Line I L& 1 LEACHING LINE L1 No. & Len,R/th�ro li�jas. �nC p Total length/size FILTER BED ❑ Distance ttS'f>�a st`ein pmp e e wultd ppc; ed Property LineA -by '. uiropm. t-i Heaath D%,:a nw SEEPAGE PITS 11 Depth Size _ Number SUMPS LI 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 rules and regulations of the San Joaquin County M Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this pgrmtt is issUod, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiiing or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman,'s compensa tion laws of California." The applicantmustcall for all required inspections. Complete drawing on reverse side. Signed X /��' r i`.c,lam- Title: L_ZC,0 Date: Z_ FOR DEPARTMENT USE ONLY Application Accepted by - 1.41,�Op-- — Date ' I ,Z— Area o 1 Pit or Grout Inspection by Date Final Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO �] '�f� RCAlISH �y� . EH 3-24 A / Cf( " " :l C" � /tel �' EH 14.16