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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 (Complete in Triplicate) I' Application Is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application In made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulatione of San Joaquin County Public Health Services. /�� Job Addressp-��'�7 �a��1R- .�/�G City ' "^" Lot Size/Acreage Owner's Name ✓ /L✓4,lr lsw Address SA000C Phone Contractor_�!� 0wrp Address 04 IYW J 7 P, _License No. 2 r Phone T14 4/7 s TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION t of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C] Domestic/Private U Gravet Pack L7 Tracy Type of Casing_ Specifications F1 Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth 1 ; Eastern Surface Seal installed by Repair Work Done U Type of Pump H.P. Stat Work Sealing Material & DepthDon�I�— Well Destruction Well Diameter .� --- Depth 0 Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION ( I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial_ Other Number of living units: a Number of bedrooms Character of soil to a depth_ of 3 feet: Water table depth SEPTIC TANK Cl 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 r FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth' Size ° Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ a� 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 Horne 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." ` ; 3 The applicant mu for a requir insAections. Complete drawing on reverse side. vy Signed X- - _ . � Title: 6 C- /`eke Date: I' F PARTMENT USE ONLY Application Accepted by t^... t,o.=� �• Date res d Pit or Grout Inspection by Date Fine Inspection by Date Addifionsl Comments:'" r Applicant - Return all copies to: San Joaquin County_Public Iieal{h,.Servicesr ` Environmental Health Permit/Services F 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFOFEE AMOUNT DUE AMOUNT REMITTED CASH CK f RECEIVED BY DATE PERMIT N0. . EH1721(REV.iins)AA) D 0 V 1.tp©.tr`o �5i-o �`� � �l 9z- f��iS EH 11.20