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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 rr P O 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 1 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. Job Address 1570. Ery p� City ti' O Got Size/Acreage Owner's Name rRC.ak �U$O _ Address A X10 101VZ'16'Y's - _— Phone ry , Contractor f OH Address "19 2 BL t`l Vas `''es. License No. V&_Je91 Phone TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ . PUMP INSTALLATION �' SYSTEM REPAIR C1 ' OTHER p : Monitoring Well L3 t DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS a INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C3 Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casing— Specifications 1'! Public' Cl Other i-i Delta Depth of Grout Seal Type of Grout I i Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done T ' Weil Destruction, ❑ Well Diameter Sealing Material 3 Depth ". Depth w. Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will server Residence Commercial_ Other r Number of living units: Number of bedrooms"' V Character of soil to a depth of 3 feet: /g h r L.0A' l Water table depth' SEPTIC TANK. M 'cType/Mfg P79- Cd S! rt C Capacity f 600 No. Compartments PKG. TREATMENT PLT. ❑ , Method of Disposal Distance to nearest: Well to O Foundation 1-�r Property Line LEACHING LINE No. & Length of lines '" `�O Total fengthlsi2e gD + FILTER BED ❑ Distance to nearest. Well /000 Foundation Property Line 1 DO' SEEPAGE PITS 11 Depth t Size 3`x f r Number 3 SUMPS Distance to nearest: Well f�t7 Foundation Property Line f vow DISPOSAL PONDS ❑ 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 County1 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, I shall employ persons subject to workman's compensa- tion laws of California." F i I The applicant must It for all required inspections. Complete drawing on reverse side. , Signed X �Z Title: t y Date: E�ft__� _ FOR DEPARTMENT USE ONLY j '1 Application Accepted by Date Areaajeq ( Pit or Grout Inspection by Date Final Inspection by Date I O Additional Comments: a� iC�i�: rf,[./'_/ fS e/ 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIV NO. INF A'O . EH13.24IREV.iiHSlSJV I'Lf•aFO 140'0 1770 EI EH 14.16