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r AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f' ENVIRONMENTAL HEALTH DIVISION •- 1 . 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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 $an Joaquin County Public Healthy�(fServices. JJ //)) I Job Address = - � !YaLO NeC1 City r�`� I Lot Size/Acreage a C Owner's Name 6 0XV 2�J �3ii(As 01 Address � �� !V �kC �A C Phone Contractor A, I f iM Address L'cense No. 3 Phone��O a� TYPE Of WELL/PUMP.--NEW-WELL❑'-—'t--WEL-L-REPLACEMENT •��DESTRUCTION-0� Out of Service Well ❑ PUMP INSTALLATION,j 1 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C� DISTANCE TO NEAREST: SEPTIC TANK Sri SEWER LINES DISPOSAL FLD. PROP. LINE d FOUNDATION AGRICULTURE WELL _OTHER WELL _ PITS/SUMPS o ` INTENDED USE _TYPE OF WELL" PROBLEM AREA CONSTRUCTION SPECIFICA'r9 NS „ D Industrial Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing Domestic/Private 0 Gravel Pack ❑ Tracy Type of-Casing e� '` S cifications \ ..._ Pe F1 Public 1-1 Ot er yn Delta of Grout Seal Type.of Iroutatnaircl, I i Irrigation 3� Approx. Depth I Easter Surface Seal Installed by >n Repair Work Done U T p r p Type of Pum �` H.P. _ - State Work Done Well Destruction ❑ `"Well-Diameter * Sealing Material & Depth r • I Filler Materiel & Depth I TYPE OF SEPTIC WORK:, NEW-INSTALLATION I ] REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is J available within 200 leet.l installation will serve: Residence +Co eicial— Other ' Number of living units: Number of'bedroams, _ Character of soil to a depth of 3 feet: ' Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal r Distance to nea?rest . .-_Well- Foundation Property Line LEACHING LINE 0No. 8 ten lh-of lines """-'"" ` . 9 Total length/size �`yy FILTER BED ❑ Distance to nearest: Well Foundation Property Line i I SEEPAGE PITSi I 'Depth Size Number, I SUMPS -LI .Distance to nearest: Well Foundation Property Line .-DISPOSAL PONDS 0 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 regulafions 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 ,,vr nifies 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- .1tion laws of California." (jTe applicant must call for all to uired inspections. Complete drawing on reverse"side. Signa X Title: J P _� Date: R DEPARTMENT USE ONLY' /f de ' Appiicstion Accepted by Date �i Area F ou"Pito G nspection by Data7ittal Inspection by Date r Additional Comments: _ � ., it Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services ,n~� �Q*,QL 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 d FEE CK AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY F�0 DATE PERMIT'N0. i EH 3.24MEV.rer C? Z12iit 0 \JEH 1Zn (rp '