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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 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 With San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servi Fes. 1 f Job Address f y, Cit Lot Size/Acreage vs-b Qu.rrr.��CtLv, c Owner's � Address one � r 1 ContrasName Address / 7_0 0 License No. Zg'ZZLo Phone �vAos TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION Ci Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing C-1 Domestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing_ Specifications CI Public 1-1 Other I-1 Delta Depth of Grout Seal Type of Grout I I Irrigation ___.Approx. Depth i I Eastern Surface Soul Installed by ( , Repair Work Done 0 Type of Pump H.P. State Work Done \j�1 Well Destruction ❑ Well Diameter Seeling Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTAL TION I I EPAIR! ODITION -DESTRUCTION I 1 {No septic system permitted if public sewer is available within 200 feet.1 . Installation will serve: Residence_ Commercial Other Number of living units: _L_ Number of be Is Character of soil to a depth of 3 feet: _ �— ' Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size Z )(:2 J-0 FILTER ED ❑ Distance to nearest: Well :522r Foundation - 145' Property Line SEEPAGE PITS [ I Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 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 ust ca r all req t spe 'ons. Complete drawing on reveVs . Signed X Title: Pd . Date: OR DEPARTMENT USE ONLY / Application Accepted bYc Date x Area y Pit or Grout Inspection by Date Final Inspection by Date Z- Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DVE AMOUNT REMITTED CASH RECEIVED BY DATE QPERMI7'NO. . EH 11 -26 1REV.i 5) S I 1Q'�►.3� ! EH 14.20 LO1 v Z -7-qz►l