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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN ''J•OAQUIN, PHONE (209)468-3420 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 Regulations of San Joaquin County Public Health /Services. Q �1 7� IV • Job Address B 1114 r City Lot Size/Acreage _(p A g.re5 l '` �l �y Owner's Name �_ I�—j e h Address "� �_� r" T 4 Phone Contractor tr�O K r Address . D � � License No. �l Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I DESTRUCTION Ll Out of Service well ❑ -PUMP INSTALLATION-0 SYSTEM.REPAIR_O--OTHER_C Monitoring Well L� DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE-WELL' OTHER WELL - _'PITS/SUMPS INTENDED USE ;--TYPE-OF WELL-2""-PROBLEMAR€A—CONSTRUCTION SPEGFIC4T'IONS— ' n industrial ❑ Open Bottom ❑ Manteca _ ' Dia.,of Well Excavation Dia. of Well Casing Ca Domestic/Private O Gravel Pack L) Tracy r . .Type of Casing_ _ -._ Specifications I'i Public f-1 Other n Delta "Depth-of^Grout Seal Type of Grout 11 Irrigation _ Approx. Depth I I Eastern Surface Sedi installed by} f^ r' _ 1T Repair Work Done L7 Type of Pumpf H.P. State Work Done Well Destruction 1:1 We(( Diameter healing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted it public sewer is _ available within 200 feet,I Installation will serve: Residence Commercial Other t Number of living units: Number of bedrooms Character of soil to■ depth of 3 feet: ' Water table depth SEPTIC TANK I� Type/Mfg �`f C-P Capacity /4,O O No. Compartments Z' PKG. TREATMENT PLT. CI �� A^ - -- '=i1* -- Method of Disposal t Distance to nearest: :..Well/bo Foundation `�0 Property Line LEACHING LINE ' No. & Length of lines 3 G b Total length/size FILTER BED 1] Distance to nearest: Well dry Foundation 1_ Property Line O SEEPAGE PITS 1}Q Depth Q Size 41,2 Number .�,r ��l SUMPS t Distance to nearest: Well �.T _ oundation _ Property tine_Cd1_] _ _ v DISPOSAL PONDS ❑ tD i2 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 rof the San Joaquin County, ! l �;I 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,:l shall employ persons subject to workman's compensa- tion laws of California." The applicleArawing� onr reverse side. ` r q Signed x <_Ar/�J Title: O K 1^ O r Date: �O,Cn DEPARTMENTUSE ONLY Application Accepted byL Date 5 L Area Pit or Grout Inspection by Date Final Inspection by Date dl � Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services zu A Environmental Health Permit/Services 445 N San .Joaquin, P O Box 2009, .Stkn, CA'95201 FEE AMOUNT DUE AMOUNT REMITTED CK 0 RECEIVED BY DATE PERMIT NO. INFO CASH 1 0A EH 11-24 IA£V.1/MS) t tC Q l7 Io�� u 3u ]—A5 EH 1 .26