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i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 I 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 application is made in compliance twith San Joaquin County Ordinance No. 549 and 1.862 and the Rules and Regulations of San Joaquin County Public Health Services. Q Job Address r (7 1` City Size/Acreage Address =� Owner's Name Phone�'" t Coriiraclor !fes-Addresses/ Jug License No. �+�Phone J� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F. DESTRUCTIO Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑' LA OTHER ❑. Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF W-i PROBLEM AREA 'CONSTRUCTIOfV SPECiFICA710NS� El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weil Casing Cl Domestic/Private ❑-Gravel Pack ❑ Tracy Type of Casing_ Specifications Cl Public ' t ` k C] Other nDelta Depth of Grout Seal Type of Grout I I Irrigation . .Approx. Depth—1-I Eastern�Surface-Seal-Installed-by- — — - -- Repair Work Done U Type of Pump H.P. State Work Done — ' Well Destruction' ❑ Well Diameter Sealing Materia]'b Depth ' Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIRIADDITION I I DESTRUCTION (No septic system permitted if public sewer is available-within 200 feet'.T- - Installation witl'serve: Residence_ Commercial_ Other f Number of living units: I Number of bedrooms Character of soil to a depth'of 3 feet: Water table depth SEPTIC TANK 1 © Type/Mfg Capacity No. Compartments z PKG. TREATMENT PLT. ❑ 4a Method of Disposal f' Distance tor inearest: Well. Foundation Property Line I f LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED n Distance 6rearest: Well Foundation Property Line ` SEEPAGE PITS 11 Depth Size _ Number : SUMPS ' '* LI 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 -' . V Home owner or licensed agent's signitura'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." The applicant must call for all requi(A inspections. Complete drawing on reverse side Signed X. Date: _U_ n � � kZ., OR D PARTiNENT USE ONLY Application Accepted by `r" Date044�_--A_rea / ll r t � g � Pit or Grout Inspection by ; i 'Da Final Inspection by Dater ►� Additional Comments. F ' Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N-San—Joaqu-kn-,TP-O-Box�2009^Stkn;""CAT952O1`FEE INFO AMOUNT DUE 1 AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. + EM 13-24 TREY.V X 51 r a1p EH 14- 7 ��