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SAN JOAQUIN COUNTYFPUYZ, C HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 /Applica p O BQX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED(Complete in Triplicate)n is hereby madeto San Joaquin Cotmty for a permit to construct andd 1 install the Work herein Mations . This n is tradein compliance with San Joaquin County Or nance No. 549 and 18b and the Rules and Regulations of San unty Public Health Services. Size/Acreage f}y City • � Job Address ` Phone Address Owner's Name 8License N T4- ods Phone Addres 2 If Contractor WELL REPLACEMENT Cl DESTRUCTION CI Out of service well ❑ NEW WELL ❑ OTHER ❑ Monitoring well C7 TYPE OF WELL/PUMP: PUMP INSTALLATION C3SYSTEM REPAID SEWER LINES �.�.---- DISPOSAL FLD. PROP. LINE i DISTANCE TO NEAREST: SEPTIC TANK ��-- OTHER WELL �-- PITS/SUMPS FOUNDATION �- AGRICULTURE WELL ` INTENDED USE TYPE OF WELL PROBLEM EM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing - pia. of Well Excavation , n Industrial ❑ Open Bottom ❑ Manteca t Specifications 'f Pack ❑ Tracy Type of Casing_ [�lbomesticlPrivate ❑ Gravel Type of Grout k f 1-1 Other C 1 Delta Depth of Grout Seal 01 i'l Public Surface Seal Installed by �" 1 I Irrigation _.Approx. ,Depth 4 Eastern State Work Done Type of Pump H.P. Repair Work Done Sealing Material & Depth s 1 Wel! Destruction ❑ Well Diameter' i A Depth Filler Material 5 Depth available within 200 feet.) TYPE OF SEPTIC WORK; NEW INST.AL•LA710N I 1 REPAlR1ADplTION i I DESTRUCTION l 1 (No septic'system permitted if ptiblit sewer is Installation will serve: Residence' Commercial Other --- Number of living units: Num11 ber of bedrooms Water table depth ` Character of soil to a depth of 3 feet: CaPacity� No. Compartments ❑ Type/Mfg` .^r. SEPTIC TAMC %; Method of Disposal PKG. TREATMENT PLT. ❑ f'S `,- Property Line - Distance to nearest:r Well Foundation ---- _ ..,... 1 ! l Total length/sire I, LEACHING LINE ❑ No. f4 Length of lines Property Line ❑ Distance to nearest: Well t Foundation _ - p FILTER BED i ;! Site Number... - SEEPAGE PITS l I Depth _ - tr^ "Property Line--L- SUMPS " - i L) Distance to nearest: Well Foundation SUMPS s J, DISPOSAL PONDS ❑., _N ' 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 prepthis permit rules and regulations of the San Joaquin County g, „ l not Home owner or licensed agent's signature [o a certifies arbecones the f lto wlorkman'srtcompensation laws Caiiforrnia."Contractor's work for which rhiri g or sub- ont act ng`signlatu e employ any person in such manner certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's ampans - tion Tawe o rnia." The licant m t call for all requir specti Complete drawing on revs e. �:. Date: Title: f Signed � R DEPARTMENT USE ONLY Date ft�1 7- Area Application Accepted by �� pp Gly.-f/pate dL- Pit or Grout Inspection by Date�.� -- Final Inspection by Additional Comments: San Joaquin Applicant - Return all copies to: Environmental aHealth unty uPermit/services blic Health vices 445 N San Joaquin B x 2009, Stkn, CA 95201 �Dt %EE AMOUNT DUE A RUNT REMITTED �K ECEIVED t?!Y DA E PIT,N0. -t� 1 . EH 53-14 IREV.t/H51 EH t1.26 I -