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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 IP O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 11 (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. v�t9 Gas :rA� �`m r Jab Address City� ��Size/Acreage Kwner's Name 1`° R �I Address Phone Contractor �` �� ✓ Address License No. Phone TYPE OF WELL/PUMP: NEW WELL C WELL REPLACEMENT n DESTRUCTION L) Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATIONAGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private 0 Gravel Pack i ❑ Tracy Type of Casing_ Specifications V1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation .._._.,Approx. Depth I i Eastern Surface Seal Installed by \^ Repair Work Done ❑ Type of Pump t H,P. State Work Done _ �3 Well Destruction ❑ Well Diameter 1 Sealing Material i Depth Depth l` Filler t O TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITI ! a 11 o wI I e err#iltfd if public sewer is r i v J instaifatian will serve: Residence t ,LCo! mmercial � may have expired without Number of living units: __L Number of bedrooms- Character of soil to a depth of 3 feet: l work beino eted,,,Wri 30 SEPTIC TANK. ❑ Type/Mfg t.f � etL $� s PKG. TREATMENT PLT.❑ i Method of Di s l Distance to nearest: Wella Foundation Property Lina '(n..� ' LEACHING LINE CI No. & Length of lines Total length/size FILTER BED n Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth t r Size s v Number SUMPS L1 Distance to nearest: Well Foundation Property Line 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 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 t employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of 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." ' The ap must call fqt all requir inspec ns. Complete drawing on reverse side. } Signe C' ' Title: �ur 0,JFid-- -- - - Date: q 4 �&EP RTMENT USE ONLY {{�� Application Accepted by Date 5` t+ Z Area k Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services F 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. + INFO . EH 13-24IREV.riwS! Ep� � S �J i 6+ � 07 EH t1.2a