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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-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 [Wade in compliance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Joh Address City_ Lot Size/Acreage r Owner's Name Address 5;?,2 & Phone 34.9-5 35 I Q6. 6t�C 767 2 7- (� 3619-5-1 0 5` Gontracto � Address �_ License f�lo,� �2 Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �- :-- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Well Casing f7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications V1 Public f_1 Other 1"1 Delta Depth of Grout Seal Type of Grout I I Ifrigation .•_._Approx. Depth I I Eastern Surface Saul Installed by Repair Work Done L] Type of Pump H.P. State Work Done _ Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material & Depth ~ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAI ADDITION DESTRUCTION i I (No septic system permitted if public sewer is available within 200 tees.I Installation will serve: Residence� Commercial_ Other �;.� Number of living units: __L Number of r oms r1 �V Character of soil to s depth of 3 feet: - Water table depth SEPTIC TANK Type/Mfg Capacity. L(0 6 O _ No. Compartments PKG. TREATMENT PLT.Cl r '� Method of Disposal r: Distance.to nearest: Well Foundation -Property Line- 'S r f r LEACHING LINE No. & Length of lines 0 Total length/size a 1( FILTER BED C-I Distance to nearest: Well r Foundation ` Property Line S r r rr 1 SEEPAGE PITS y^l. Depth Q Size Number r , SUMPS ll Distance to nearest: Well to Foundation 10 Property Lina _ S DISPOSAL PONDS p 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 work1for,whjdh,this permit is issued, I shall not employ any person in.such manner as to become subject to workman's compensation laws of Calif ornia.""Contractor'shiring_6i sub-ccontracting signature certifies 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- tion laws of California." The applicant m all for a u' d inspections. Complete drawing on reverses t 1 Signed Title: _ _ Date: FOR DEPARTMENT USI< ONLY Application Accepted by _� -__ d-�� ,.J Date �� AreaA/tZ or Grout Impaction by Date Fina! Inspection by -' Date7 ''�2 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 FEE CASH DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE �� PERMIT'NO. NFO. EH13-14(REV.t/K 61 * l i "n //y�d a �W tJ .� cl'�✓��. EH 114.25