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r r5 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES J 2 r rl o �(,r-t cl e ENVIRONMENTAL HEALTH DIVISION 1 V 445 N SAN JOAQUIN, PHONE (209)468-3420 m Jp4r�a 14 P O 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 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 .�_� � ,3o` L) — City Lot Size/Acreage SL"I �'1{��.LJ Address �D I-�.11 C� afii.- _ Phone — 32Owner's Name ---- ' a ContractorPAddress License Ito. 4'6 761 Phone TYPE OF WELL/PUMP: f NEW WELL ❑ WELL REPLACEMENT rl DESTRUCTION n Out of Service Well L1 i PUIOP INSTAILLATiON 0 SYSTEM REPAIR OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -DISPOSAL FLD. PROP. LINE FOUNDATIOt F AGRICULTURE WELL __ OTHER WELL_. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ pen Bottom ❑ Manteca Dia:of:Weil Excavation Dia. of Well Casing F Domestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ / t Specifications Public 1:3 Other ? n Delta Depth of Grout Sell ; ",i Type of Grout i I I lrrigation k Approx. Depth I I Eastern ftrface-Sealnstallld hyo j r i Repair Work Done U Type of Pump`- _ H,P. State Work Donees _ Well Destruction ❑ Well Diameter f Sealing Materiel &Dep•trh _ -s Dep[h 'uPillex'.Idateri'al & Depth TYPE OF SEPTIC WORK: NEVV4NSTALLATION I 1 REPAIWADDITION i I DESTRUCTION-1 I (No septic system permitted if public sewer is V( } available within 200 feet.i Installation will serve: Residence% Commercial— Other Number of living units: Number of bedrooms PAYMENT Character of soil to a depth of 3 feet: Water tth SEPTIC TANK C3Typt,/Mfg I Capacity No. Core !sIN PKG. TREATMENT PLT. 0 � i � � MsthodW@sp44I 1992 Z5�. Dist na ce tti nearest: Well Foundation Property U) u u�I�I,I Y LEACHING LINE Cl No.-8!Length of lines Total lengthy If `' - tj .slol FILTER BED n nista ce tri nearest: Well Foundation Property Line •r SEEPAGE PITS i I Dep'th� Size ^ Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS= —0 —---e 4 -- 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 JoaquinCounty- ra Home owner or licensed agent's signature ce'rtifie's the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any pets in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the foil i g: "I cortify that in the'performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o a nia." �pli.n. The appfic t st call for all requir n late drawing on rev se s e. Signed t Title: Date: ` DEPAR7MIENTIUSE ONLY 3`1 ^tet 2 Application Accepted by Cr.._ rL► .- } ` 1 Data Area Pit or Grout Inspection by Date Final Inspection by Date 1 til a�'Additionpl-Comments: _ -. _ - _ Applicant - Return all copies`to: San Joaquin County Public Health Services Environmental Health Permit/Services { 445 N San Joaquin, P ox 2009, Stkn, CA 95201 FEE I AMOUNT DUE AMO T REMITTED CK RECEIVED BY ATE PERMIT N0, FH 14. fREV. 11 K