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�,, ' SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN J'OAQUIN, PHONE (209)46$-3420 j P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r i (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This i application is made 1n complience with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San i Joaquin County Public Health Services. 'A Job Job Address •/� '-""'- k City i-Jv Lot Size/Acreage IQ LS ,/.' Address/�['� 3 it xpt Phone s Z Owner s Name _ l Contractor e/ Address's �� License N��L _Phone TYPE OF WELL/PUMP: ;_, EW WELL WELL REPLACEMENT Cl DESTRUCTION Out of Service Nell ❑ PUMP INSTALLATION W:� SYSTEM REPAIR 0 OTHER p Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNOATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ^- 3 3 L7 777 Industrial ❑ Open'Bottom ❑ Manteca Dia. of Well Excavation T Dia, of Well Casing /af/C �$- y( Domestic/Private. .'Gravel Pack ❑ Tracy Type of Casing_ Pe I'I Public fa Other ! F1 Delta Depth of Grout Seal Type of Grout qrruza& I I Irrigation '3�> _.Approx. Depth i I Eastern Surfac edi installed by. Repair Work Done L7 Type of Pump H. State Work Done C Well Destruction ❑ Well Diameter Sealing Material & Depth Depth i Filler Material & Depth fT� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.i i Installation will serve 'Residence Commercial_, Other b _ T Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/Mfg _ 4 Capacity No. Compartments"_-, PKG. TREATMENT PLT. 0 M� Method.of'Disp6sal Distance to nearest: Well Foundation Propeity-Line l " LEACHING LINE ❑ No. & Length of line's Total length/size FILTER BED n Distance to nearest: Well Foundation Property.Line SEEPAGE PITS l I Depth Size Number SUMPS CI Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑ ! rt 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 11 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 becomes bjeetao workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I cartify that in th_a performance of the work for which this permit is issued,I ihall employ persons subject to workman's compensa- tion•laws of California.'.__ Theapplicant must c 11 for IZeired inspections. Complete.drawing on?evetse side. I. Signed Title: ff✓y " Date: 6 4DEMENT USE ONLY -- , Application Accepted by Date Area, Pito Grout in do y I inspection by>Additional Comments: ` ' ` { 73 d d Applicant - Return all copies to San Joaquin County Public Health Services Environmental Health Permit/Services h ` 445 N San Joaquin, P 0 Box 2009, Stku, CA 95201CK 9 AFEF_ AMOUNT DUE i AMOUNT REMITTED CASHRECEIVED BY DATE PERMIT'NO. G; ,. 5i$ 3 J*JV0EH 13.24 t4EV.ti * © D t*� 6 yX- 3e 7 EH 71-26