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- - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,'- PHONE (209)468-3420 ' P O BO%2009',"` S'TOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) Application is hereby made to SJoaquin County for a permit to construct and/or install the work herein described. This application is made in compliance liance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. � //f` ! Job Address v.. WL �,r�r ?'��•r/t3�`�TR LV} Git of S ze/A re e - � , Owner's Name Address •L�m.L Phone Contractor �� Address agQk I?Z.-lZ� License No. W� Z 3 7 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 FLO. PROP. LINE r f FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS ; INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial © Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing Ca Domestic/Private ❑ Gravel Pack ❑ Tracy '�. Type of Casing_ Specifications R y Fl Public Cl Other t f-1 Delta Depl of Giout.!Seat Type of Grout I i Irrigation Approx. Depth I I 9stern Surface Seal jnstalledlby Repair Work Done e_ Type of Pump H,P. S �.State Work Done v Well Destruction O Well Diameter Sealing Material & Depth Depth t v Filler Material & Depth i TYPE,OF SEPTIC WORK: NEW INSTALLATION I`[ REPAIR/ADDITION I'I 'DEST,RUCTIO I-1\(No septic system,permitto.cl if6public-sewer is � 1 yy -r= . � .z r ,a-s `� v available 6bin 200 leet.I V Initallation wilt-servel—Residence�Conimerdiil" '^ Other""-'-"""-'""""" _ -- -- .-- . ., N, Number of living units: Number of bedrooms S Character of soil to a depth of 3 feet: Water.table depth SEPTIC TANK. J j ❑ Type/Mfg C acity No. Compartments PKG. TREATMENT PLT. ❑ rMethod.of Disposal Distance to nearest: Well F n ion Pfopohy Line LEACHING LINE `, Ll No. & Length of fines Total length/size FILTER BED ❑ Distance to nearest: Welt Foundation Property Lino SEEPAGE PITS E n 11 Depth t Size Nuerperty Line 0 SUMPS LI Distance to nearest: Well IF Foundation DISPOSAL PONDS 't ❑ . \� 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 1\•� 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 employan t y per to s ._h.manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the f owing: "I rtifyih'a7 in the-oariormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o Califor Is." *- The appli ant II req14 i omple a draw Signed d Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Oar Date Area Z Pit or Grout Inspection by Date Final Inspection by-222LDate 7 .- r�. Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Pe it/Services 445 N San Joaquin B 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CA RECEIVED BYATTjjjE PERMIT NO. " EM 13-24 IREV. i n s) ! p� EH U-2e �r d� (�(J J LL