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-•� SAN JUIN COUNTY PUBLIC HEALTH 5 VICES ENVIRONMENTAL HEALTH DIVISIOR' 445 N SAN JOAQUIN, PHONE (209)468--3420 P 0 BOX 2009, -STOCKTON, CA 95201 PERMIT EXPIRES I 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 SQ. Q City [_o V1% Lot Size/Acreage Owner's Name r V%IL �� 5��1 Address 11�bS� S�.t Phone 3 Contractor f.LLI ��` Address DtCt S�- +^ License No.kl 1 b Phone Zjcr4 -3Se. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION r❑ SYSTEM REPAIR C1OTHEIR Xd Monitoring Well C3DISTANCE TO NEAREST: SEPTIC TANK ~ GO SEWER LINES --10 DISPOSAL FLO.�0 PROP. LINE 3 r FOUNDATION �� AGRICULTURE WELL &1_&.__ OTHER WELL-7 SD PITS/SUMPS ..— INTENDED USE TYPE OF WELL PR08LEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing n Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing Specifications I'I Public n Other fl Delta Depth of Grout Seat Type of Grout \ I I Irrigation —.Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth D Filler Material i Depth futL"', TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I 1 DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial _ Other PAYMENT Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: R E C E f V E■+u Water table depth SEPTIC TANK. ❑ Type/Mfg Gapi�y No. Compartments PKG. TREATMENT PLT. ❑ rK U 1 M14 Method of Disposal Distance to nearest: Well FounQ h 10AQ_ INC 9&Vehy Line PUBLIC HEALTH SERVICES LINVUHUNMMAL LEACHING LINE El No. & Length of lines o a en WffiLON FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 1 Depth Size Number _ SUMPS LJ Distance to nearest: Welt Foundation Property Line " DISPOSAL. PONDS ❑ I hereby certify that 1 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 applicant must call for all required inspections. Complete drawing on reverse side. Signed X �a`d"' ,}- Title: �cc, ��x1`eca�1� --- Date: 3 4 Ld FO EPARTMENT USE ONLY N Application Accepted by Date 7 " Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services 445 N San Joaquin, Health permit/Services 445 N Sas Joaquin, P O Hoa 2009, Stkn, CA 95202 FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED 9Y DATE PERMIT'NO. INFO M2a EH 13.24 iREV.1/]%5l EH t