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�! SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 II P 0 BOX 2009, STOCKTON, CA 95201 iI PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 0 Application is hereby made.to Sen Joaquin County for a permit to construct and/or install the work herein described. This application is made in cemrlialnce with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services.11 r Job Address / / '_ !/�yr�J� G/� }� _ City Lot Size/Acreage �/ / t� Owner's Name, I�f�tU �`d'�r � f Y��Address Phone Contractor ''C'p, Address 496vtosvZol. License No, J Phone TYPE OF WELL/PUMP: .i NEW WELL ❑ WELL R PLACEMENT C7 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ElSYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 F- Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r f.l Domestic/Private 0 Gravel Pack ❑.Tracy , CiType of Casing__ Specifications f'I Public -1 Other - %n Delta Depth of Grout Seal Type of Grout I i Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by h Repair Work Done 13 Type of Pump H,P. f State Work Done Well Destruction ❑ Well Diameter Well Material & Depth Depth; .Filler Naterial_.A..Depth ' TYPE OF SEPTIC WORK: - NEW1` INSTALLATION REPAIR/ADDITION I I DESTRUCTION I l {Na septic system permitted if public sewer is \ �I 1 available within 200 leet.I Installation will serve: Residence L Commercial... Other Number of living units: -j _j Number of bedrooms,3° Character of soil to a depth of:3 feet: - ib�� _ Water table depth ' SEPTIC TANK. ❑ Type/Mfg Atf Capacity JA OD No. Compartments PKG, TREATMENT PLT. ❑ II. Method of Disposal Distance to nearest: Well jFoundation Property Line OG II ' LEACHING LINE f[1` No. & Length of lines f Total length/size FILTER BED C7 Distance to nearest: Well Foundation �Q Property Line 4 SEEPAGE PITS e Depth jl. a Size 36 �r J ls9•.- ' '� Number SUMPS L1 Distance to nearest: # Well �� Foundation O ' Property Line �O DISPOSAL PONDS ❑ I t ii 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'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 errlploy persons subject to workman's compensa- tion laws of California." II The applicant mug call for all required inspections. Complete drawing on reverse side. Signed X Title: Date: 3G Elf FOR DEPARTMENT USE ONLYApplication Accepted byDater Area it or Grout Inspection by Data 13 _ Final Inspection by Date l Additional Commants, II, ii Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services a I! 495 N San Joaquin, P O Box 2003, Stkn, CA 95201 FEE AMO NT RIFE AMOUNT REMITTED CASIVED BY 0 E PERMIT'N0. INFO E! `5 a] 17.9 - . EK13-24(REV.1r Rb) EM 14.25 �ll it