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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 —/�C c;�U_�,I� PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete iTriplicate) ompee n rpTS t q� - 4 a Z9 Application is hereby made to San quin County for a permit to construct and/or install the work herein described. This application is made in 11-ance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health �Services. r 640 X&O Job Address c City Lot Size/Acreage Owner's Name � �j jBM4J �1 - Address :5 -r � Phond J 16 Contraclo Address License No.� Phone 1-411 TYPE OF WELL/PUMP: 1� NEW WELL ❑ WELL REPLACEMENT C� DESTRUCTION Wout of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ i 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 n Industrial ❑ Open'Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing L.l Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications a ('1 Public f-1 Otherl 171 Delta Depth of Grout Seal Type of Grout I;1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by t t Repair Work Done U_�ype of;Pump H,P. tate Wok Done _ 4 Well Destruction Weft Diameter sealing Material i Depth *� 4 Depth I. JAQ Filler Material Depth " I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other p � Number of living units: Number of bedrooms Character of soil to a depth of 3 h`feet: Water table depth SEPTIC TANK. 0' Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line II , LEACHING LINE 0 No. 8& Length of lines Total length/size k FILTER BED ❑ Distance to nearest: Well Foundation Property Line I - SEEPAGE PITS l I Depth Size Number SUMPS LI Distance to nearest: Welt Foundation Property Line —DISPOSAL PONDS. ,0.. _ a ,. _ - W _ s _- 1 --_. - -- ,.., �^_ -- =_ = r I hereby certify that f 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 Ii used agent's signature certifies the fotlowing: "I certify that in the performance of the work for which this permit is issued, I shalt not employ any pe in such manner as to beco a subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fo c fy that in she ormance of the work for which his permit is issued, I shall employ persons subject to workman's compensa- tion laws of nia." III The ap ica st c I f all aqu'red ins ctions. Complete drawing on r er ids. } Signed Title: Date: r FNT USE ONLY R D PARTME Application Accepted by Data Area Pit or Grout Inspection by I� Date Final Inspection ate Additional Comments: I� i 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 AMOUNT DUE AMOUNT REMITTED I RECEIVED BY DATE I PERMIT'NO. INFO y . EH tta-s4 tnEv. x s, Et-2C !� ®� r E�,o 077/ ,S �. 4d; C H 4 I _J•