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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 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 work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regul�tlons of San Joaquin County Public Health Services. % J� Job Address"� ! 3/��'�`Gity Lot Size/Acreage `-- Owner's Name � � AecTess Phone Contractor_4� +�� YCddress License No. � % Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION' SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well �� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELI�� OTHER WELL PITS/SUMPS INTENDED USE n Industrial Domestic/ Private Il Public I I Irrigation Repair Work Done Well Destruction U TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom Cl Manteca Dia. of Well Excavation _t - XGravel Pack7. ❑ Tracy Type of Casing - 1 -1 Other f7 Delta Depth of Grout S'sal O�i )Ap rox. Depth I I Eastern Sy ace Seal Instlafed by Type of Pumps H.P. .� State Work Done _ Well DiametaL iOl t Sealing Material & Depth Depth Y� Filler Material & Depth OF SEPTIC WORK: NEW INSTALLATION ( I REPAIR/ADDITION I I D Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Distance to nearest: Well LEACHING LINE ❑ No. & Length of lines FILTER BED C) Distance to nearest. Welt H Dia. of Well Casing Specifications —e -- Type of Grout... ON I I (No septic system permitted if public sewer is available within 200 feet,) Water table depth - Capacity No. Compartments Method of Disposal Foundation Property Line Total length/size— Foundation ength/sizeFoundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll 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, stale 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 subcontracting 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 't 6adXall qui rsd to ns. Complete drawing on revs se side. Signed X Title: Date: / DEPARTMENT USE NLY c Application Accepted by • Date �� L %-- Area q �p fZ`"�Z Final Inspection by Data `"3✓ _ i Pit or Grout Inspection by ate p " p -Additional Comments: C _ — (! S { r,.e �I t l r rut, t tnt Applicant - Return allrcopieeto: San Joaquin County Public Health Services Environmental Health permit/Services 445 N San Joaquin, Box 2009, Stkn, CA 95201 . EH 13-24 IREV. t 1 h 5 EH t4•le FEE INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY D TE P RMIT NO. witt11 ICN. fo �� WD 01