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i f l SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, 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. Job Address ` r � < At, 1AJk—?9 - ___. ._ City LOQI Lot Size/Acreage Owner's Name �T 1 I 1C U C-IQ AJ Address M f� + 9SZ7Tl Phone "G Contractor Ak MAS�i. C Addres-s,- � License No-5--c M Phone TYPE OF WELL/PUMP: NEW WELL �0 WELL REPLACEMENT Cl DESTRUCTION 0 Dut of Service Well 0 . PUMP INSTALLATION LSV SYSTEM REPAIR 0 OTHER ❑ Monitoring Well 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 Ll Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ik6omestic/Private 0 Gravel Pack 0 Tracy Type of Casing_ Specifications Il Public Ci Other C1 Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth I I Eastern Surface Saul Installed by _ Repair Work Done 0 Type of Pump ��Q H.P. c��J''�� State Work Done 1ZPA1 Well Destruction ❑ Well Diameter Sealing Material & Depth ljtl Depth Filler Material 8 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet,) Installation will serve: Residence_ Commercial— Other \� I Number of living units: Number of bedrooms �\ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS E."IT Distance to nearesti Well Foundation Property Line 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." Contractors 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." The applicant s II for all required ction Complete drawingo verse ide. A� l Signed X Title:� _ J Date: FO DEPARTMENT USE ONLY Application Accepted by �c �— Date Area Pit or Grout inspection by Date Final Inspection by �,/�/d Date Additional Comments: 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. EK! EH[17aIREV.riM51 Oa SD--7 t