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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2609, 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 1662 and the Rules and Regulations of San Joaquin county Public Health Services. /! .2/ OAl�c' 1 L A� City Sr7<nI Lot Size/Acreage oZr 3 Job Address � Owner's Name .r A Address �Am� Phone Contractor F��lZ Address N- License No._�/.�Z�� TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT DESTRUCTION O Out of Service well O PUMP INSTALLATION Q SYSTEM REPAIR ❑ OTHER -1 Monitoring Well L� 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 Dia of Well Casing Cl industrial CIOpen Bottom ❑ Manteca Dia.of Well Excavation Specifications C OomesticiPrivate O Gravel Pack ❑ Tracy Type of Casing_ Type of Grout v' i'I Public Cl Other f Delta Depth,of Grout Seal i l Irrigation —ApWox. Depth I I Eastern Surface Seal Installed by Repair Work Done L1 Type of Pump H.P. State Work Done, Well Destruction O Well Diameter, Sealing Material & Depth Depth IYller Material d Depth TYPE OF SEPTIC WORK; NEW INST/A/tLATION REPAIR/ADDITION ; I DESTRUCTION I I INo septicavailable Thin 200 feet�led it public sower is Installation will serve: R idence! Commercial_ Other Pa Bt Jam:. AIA 7-"-- Number � Number of living units: F Number of bedrooms _ l Character of soil to a depth of 3 feet: Ad-,A J/ Water.table depth SEPTIC TANK O TypelMfgPi:21-- Capacity No. Compartments 2- PKG. TREATMENT PLT.C7Method of Disposal nc Distae to nearest: Well Foundation !© Progeny Lina --- LEACHING LINE E< No.& Length of lines Property Total length/size .� !d FILTER BED 9 ❑ Distance to nearest: Well LUIA Foundation— Line-' SEEPAGE PITS 111'Depths�! Size�Z _ Number 3 SUMPS CI Distance to nearest: Welt ^� +Q foundation /n Property Lane r i - DISPOSAL PONDS ❑ r 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 ruies 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 w employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature Certifies the following:"I t;enity that in the performance of the work for.wlSich this permit is issued,I shell employ persons subject to workman's compansa- tion laws of California." The applicant must cag for all required inspections. Complete drawing on-reverse side. f s -p Gr1, Q Title: ��,t, � Date: 9—9-g z Signed X� '} C FOR DEPARTMENT USE ONLY q Area _Z11 /J Data Application Accepted by t \f. Date 1D � Pit or Grout inspection by Date Final Inipectlon by Additionat Comments: i 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 FFE AMOUNT DUE AMOUNT REMITTED CKaRECEIVED BY DATE PERMITNO. CASHEH t}2lIRtV.i/>151 f va'. � -A-6 EH 14.25