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i r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �.. 445 N SAN JOAQUIN-,'x 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 Services. 00, Job AddressZ"L*77A AA As Cit . of Size/Acreage w3kip 4 -2�e JUL Owner's Name dress +} 1 7 Phone Contractor t4�1111Address V _. License No( 6 4Phone i TYPE OF WELL/PUMP:. NEW WELL C *WELL REPLACEMENT ❑ DESTRUCTION ❑ out of Service Well ❑ `'^'-PUMP INSTALLATION --SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 � r DISTANCE TO NEARtO: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 1 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I C1 Industrial 1 ❑ Open Bottom © Manteca w,�.y Dia. of Well Excavation Dia. of Well Casing El Domestic/Private � 0 Gravel Pack C1 Tracy kType of Casing_. Specifications F1 Public i El Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation a _ Approx. Depth I I PasternI3-. •Surface.SSt+! Installed by Repair Work Done (Y Type of Pump H.P. 5 State Work Done Well Destruction Q Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.I !n tallation�will serve: Residence— Commercial— Other e- 1 y.-•.......w Numberr of living units,;.=-- --_�Number at bedrooms Character of soil to a'deprh of!'feet: Water table depth SEPTIC TANK. O R'TypelMfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal { Distance to,nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Len tfi of lines *. _ —_,To,tal length/size g _..1p _=- - } I FILTER BED 0 Distance to neaiest: Welt Foundation �'� Property Line - i � SEEPAGE PITS ' 11 Depth Size 9 Number SUMPS Ll Distance to nearest: Well Foundation _ Property Line DISPOSAL PONDS ❑ i, -t := I hereby certify that I have prepared this application and that the work will be cl 6e�in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner agent's signature certifies the following: "I certify that in the periprmance of the work for which this permit is issued, I shall not employ an rson in s h manner as to become s act to workman's compensation laws of California," Contractor's hiring or sub-contracting signature certifies t e followi :;'1 ertify that in,4hqperfo an a of the work hof which this permit is issued, I shall employ persons subject to workman's compensa- tion law of Caflfo a;" The ap ficant all f II r n rawing o siA d�'. Signed X Title: Date: 1 { )�nDEPARTIMENT USE ONLY Application Accepted liy Date A.3, Area afx y 4 Pit or Grout Inspection by-, Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O BOX 2009, Stkn, CA 95201 FAM TED CK RECEIVED BY DATE PERMIT'NO. EE MOUNT DUE UNT REMIT ICASH NF . EH 13.74 1REV.s/"5 y5r��c A//SIL13-113 19 3 EH 114'20 ..