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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 coupliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address ` City // Lot Size sage Owner's Name d Address Al/ � _ Phone �cz c r Contractor .f mss r� �K6nAddress iCense No. Phone TYPE OF WELL/PUMP: NEW WELL E3 WELL REPLACEMENT fl DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR 0 OTHER 0 Monitoring Well 0 DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE, k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation _ Dia. of Well Casing [-I Domestic/Private 0 Gravel Pack7 ❑ Tracy Type of Casing_ Specifications \ I'I Public Cl Other f1 Delta Depth of Grout Seal Type of Grout \ I I trrigation — Approx. Depth I ) Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Weil Destruction O Well Diameter _ Sealing Material & Depth (' _ Depth Filler Material i Depth 1v►�\` TYPE OF SEPTIC WORK: NEW INSTALLATION I I AI ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is .0 available within 200 feet.) Installation will serve: Residence__._..--Commercial— Other Number of living units: r-- Number of bedrooms Character of soil to a depth of 3 feet: � Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity MI'A-9 _ No. Compartments PKG. TREATMENT PLT. ❑ _ � Method of Disposal Distance to nearest: Well _1204 Foundation Property Line LEACHING LINE L) No. & Length of lines Total length/size FILTER BED CJ Distance to nearest. Well Foundation Property line SEEPAGE PITS 11 Depth I Size �a8,-k _ Number - <19P t_1 Distance to nearest: Well Std- Foundation A74- Property Line_<2L DISPOSAL PONDS 0 1 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 shalt not employ any person in such manner as to become subject"to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I"certify that in the performance of thework for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must ca for all required inspections. Complete drawing on reverse side. I.#- l jr/!d--9� Signed Title: Date: FOR DEPARTMENT USE ONLY f Application Accepted byDate — Z Area _2 1 ci Pit or Grout Inspection by Date Final Inspection by Oate '� Z Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/services 445 N San Joaquin, P—D Box 2009, Stkn, CA 95201 FEE AMOU T DUE AMOU T R M TIED �K CEIVED BY E PERMIT N0. I FO rHOW /1qj� EH[3.24 iREV.tin51 /, L57 1 / EH 1426