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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 9520-1 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 is made in compliance ;*with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San j Joaquin County Public Health Services. Job Address l 001 If !Y� i�J � City Lot Size/Acreage t - k Owner's Name _ �.?�}.1.14:f Tc7Q+7+tG�Ss� Address /0Re> Phone Contractor �C Address r License Nave_Phone00, TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT F.] DESTRUCTION 0 Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ + OTHER Q Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL'FILD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I' Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private C1 Gravel Pack 0 Tracy Type of Casing_ Specifications V1 Public 1.1 Other F7 Delta Depth of Grout Seal Type of Grout I I Irrigation — Approx. 'Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material & Depth Depth 1 Faller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is J available!within 200 feet) Installation will serve: ResidenceCommercial_ Other \ Number of living Unita: Number of bedrooms Character of soil to a deplK of 3 feet: J Water table depth SEPTIC TANK -of Type/Mfg __.. Capacity-+� No. Compartments gil- PKG-. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well FoundBtta f Property Line �r� 1 LEACHING LINE ..I 'I�o. & Length of lines —Fc`2Q �T_ Total length/size_ZMACI FILTER BED 1-1 Distance"toitearest:-, Well-62P-4C---T Foundation �,�JF77 Property Line 5 SEEPAGE PITS I I Depth $iza� � � Number_ - SUMPS Distance to nearest:'` �'Well/fiz2'yfl1r _ Foundation EAU I`* -,_•,_-Property.Line,-4'�_f� r DISPOSAL PONDS ❑ � 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-c6ntracting 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• ��JJ tion laws of California." ► The applicant must call for j#risgored in Pions. Complete drawing on reverse side. J Signed X 49 r Title: D81e: =V i FO DEPA w Application Accepted by }" Date Area Pit or Grout Inspection by 3 Date Final Inspection f Additional Comments- App-licant omments:Applicant - Return all copies to: San Joaquin County Public Health Services ° Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, S 95201 r b I INFD AMOUNT DUE 9AM UNTREMITTED CK ECEI ED BY DATE PERMIT'ND. , • EH 43-24 1REV.i i n si l - j /+•/ EH 14.26 ` oc�/// V i