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f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 _PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application in 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. 5L9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. / Job Address V`Ivoteov 4!y �04C ty _/1Ctr Lot Size/Acreage Y+/ Owner's Name OCA Rrt lgeAI g Address _-__ g q�r a r`JM kCI Phone �°O -,p �7 Contractor �! -5e,04'12.� AddreslliPO' / �� r License No., �' Phone 3 � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L; DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS '~ 11-1 Industrial ❑ Open Bottom i_1 Manteca Dia. of Well Excavation Ota. of Well Casing JA i 1 Domestic/Private U. Gravel Pack' L7 Tracy Type of Casing-. Specifications i'1 Public L'. Other, n Delta it Depth of Grout Seal Type of Grout f I Irrigation Approx, Depth I 1 Eastern Surface Seal Installed by i Repair Work Done 0 Type of Pump N.P. State Work Done_ r Well Destruction ❑ Well Diameter Sealing Material.& Aepth Depth " L_f fFiller Material Z Depth TYPE OF SEPTIC WORK:. NEW INSTALLATION ! I EPAIRA0.DDITION I I DESTRUCTION I ; 1No sapitc system permitted if public sewer is *+ av3,lable within 200 feet.) Installation.will serve: Residence_ Commercial —.r Other_ t I- _ Number of living units: _J_ Number of bedrooms_ 3 Character of soil to a depth of 3 feet: A Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well - Foundation - Property Line (� LEACHING LINE 0 No. b Length of lines _ Total length/size t� FILTER BED O Distance to nearest: Well fgOqL Foundation 10¢ Property Line Sd- SEEPAGE PITS 11 Depth .�. Sa. Numbs SUMPS Ll Distance to nearest: Well /40-4- Foundation lqf- Property Line r DISPOSAL PONDS ❑ 1 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 x Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this perrrwt is issued, I shall nor employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature 1 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 musl�cy I for all required inspections. Complete drawing an reverse side. Signed X Title: Date: DEPARTMENT USE ONLY Applicatlon Accepted by � �IGI•.lY Date Area i Imo' Pi r Grout Inspection by� Dal ' 2e Final Inspection by if CAesZ Date l e� Additional Comments: Applicant - Return all copies to; San Joaquin County Public Health Service...'- Environments] ervicesEnvironments] Health Permit/Servicers 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT NO. INFO _W T EM 3-24 INEV.cine 3* EN tela