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k , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 67 X 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 200911, STOCKTON, CA 95201 1 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ?Zug ger9c,c (Complete in Triplicate) Application 1s 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 Ordina ce No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health'Services. Job Address gyp: - LC— Y City�(`--�— Lot Size/Acreage j If Owner's Na v .Address �� ey _- -_ Phone ll Contractor U Address � License No �Q d I'tlone TYPE Of WELL/PUMP: 11 NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well Ll PUMP INSTALLATION ElSYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE 10. FOUNDATION AGRICULTURE WELL OTHER WELL _— PITS/SUMPS _ INTENDED USE TYKE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f.] Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing_ Specifications CI Public Cl Other I ❑ Delta Depth of Grout Seal Type of Grout J Irrigation ��Apnrox, D _ ' I�liiastern Surface Seal Installed by 4 Repair Work Done '?I- Repair oSealing Material & Depth Pump P H.P. 02 0 _ State Work Done/_e9& " Well Destruction ❑ Well iameter Depth Filler Material 8 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDiTION I i DESTRUCTION I i iNo s septic le withm emitted if public sewer is f Installation will serve: Resid'e`nce— Commercial_ Other i r Number of living units: 0 Number of bedrooms; _ L, Character of soil to a depth of 3`fest: Water table depth SEPTIC TANK; © Type/Mfg,/'�, Capacity No. Compartments PKG. TREATMENT PLT. ❑ ` I L Method of Disposal Distance to nearest: Well Foundation '' Property Line Q _ LEACHING LINE C1Nllength/size o. & Length of lines Total FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ IM .., 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 cenifieis-the following:, 'l,cilil that in the performance of the work for which this permit is issued, I shall not employ any person in such marina'r as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I canify,€that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compansa- tion laws of Cal' k .k The appfic t must c for all required ' ctions. Complete drawing on raver de.I' Signed X f Title: Date: f II t OR DEPARTMENT USE ONLY Application Accepted by ��0 _ Date 2— Area Pit or Grout Inspection by I! Date Final Inspection by Date Additional Comments: Applicant -'Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 CK 8 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. INFO EH 13-24{REV,r 1 x 54 l © �a Q ,� 2 `-� Eli 14.2E