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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION �/ 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR,FROM DATE ISSUED ft (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 2662 and the Rules and Regulations of San Joaquin County Public Health Services. ^fir 'l Job Address �. Xi' S 4 E kes G152r21 SOS �K- I City. ��/�� Lot Size/Acreage Owner's Name `f Al A! Address s � Phone 13�L 3_IX 7- Contractor �-O �t7 Address �. License No. �_�6_-Phone of Service well ffF TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT �l DESTRUCTION G3 Out Monitoring Well PUMP INSTALLATION 71SYSTEM REPAIR ❑ OTHER ❑ 1DISPOSAL FLO. PROP. LINE DISTANCE-TO NEAREST:-SEPTIC TANK.. -SEWER LINES . FOUNDATION AGRICULTURE WELL'' OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C-) Industrie! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing c— D Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications (31 Il Public fa OtherI n 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 '' i Sealing Material & Depth Well Destruction ❑ Welt Diameter Depth kJ Filler Material'& Depth i TYPE Of SEPTIC WORK: NEW INSTALLATION X REPAIR/ADDITION I k .DESTRUCTION I I Mo septic system permitted it public sewer is available within 200 leet.I Installation will serve: Residence✓ Commercial_ Other P0,61-IC- k1A 7-2T-A Number of living units: ___Z_ Number of bedrooms Character of soil to a depth of 3 feet L _Water table depth Ij SEPTIC TANK ❑ Type/Mt 1 Capacity No. Compartments I PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well WA Foundation Zo Progeny Line f �(o Total len th/size O LEACHING LINE No. & Length of lines g FILTER BED { ❑ Distance lb nearest: Well A4 A -- Foundation _ 7-r,- Property line �s l SEEPAGE PITS IFf Depth V 1 /�S� _Si:e �Zf Number SUMPS LI Distance to nearest: Well�- Foundation SOS -- Proparty-Lined DISPOSAL PONDS ❑ .�.---------- L"r" 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 isignature certifies the following:'"I certify that.in the performancer 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:" Gontfector 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 amployfpersons subject to workman's compensa- tion laws of California." , The applicant must call for all required inspections. Complete drawing on reverse side. Signed X.�_ `"'` Title: -- Date: j fy ,.r`FOR DEPARTMENT USE ONLY r d Date Area 1 11 Application Accepted by Pit or Grout Inspection by Date Final Inspection byk�jm Date Additional Comments: Applicant - Return all copies-to: San Joaquin County Public Health Services :j. Environmental Health Permit/Services -445-N San' Joaquin, P 0-B ox 2009�Stkn,CA KJ5201— " 1 FEE AMOUNT OVE AMOUNT REMITTEDCASH ` RECEIVED BY DATE PERMIT NO. INFO . EM13-24(REV.+/Ks) EN 14.26 /