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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Iv 0 Lu ell ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 Es. oc_lC Cw/�t?lI4 P 0 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 vork herein described. This application is rade 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 13 City ® Lot Size/Acreage box IZA Ownef's Name O Address rd Phone i Contractor �3 ® Address � &V&7k9Kh0License No. 35 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C1 Monitoring Well ` DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL—....._. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing [] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications C1 Public Cl Other n Delta Depth of Grout Seal Type of Grout C' i d1 Irrigation —Approx. Depth 1 I Eastern Surface Seal Installed by 9Z$ ' Repair Work Done L7 Type of Pump H.P. State Work Done 1 r Welt Destruction ❑ Well Diameter Sealing Material & Depth J Depth Filler Material A Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is available within 200 feat) vvv Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth A, SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments i PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line �5 r LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED [_f Distance to nearest: Well Foundation Property Line fn r SEEPAGE PITS l I Depth Size Number y" I 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 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 applic all fofired ins coons. Complete drawing on reverse side. r Signed Tide: t )% 424RDate: ?" 1,S Q�- F DEPARTMENT USE ONLY �} Application Accepted by C e"` - � � _ Date " t� Area ZPit or Grout Inspection by Date Final Inspection by XXAW� 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 MOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERM!IO. N INFO CASH ^� p.��jr # . EH 13•251REY.1/n31 S� � f� 7�f�7 l—l��' t /r ' EH tl•Te 4