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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 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. r Job Address City Lot Size/Acreage OF Owner's Name ^ten � � ' ' ee—d ^, Address p �y Phone 36 3 r5) g M1 Contractor Address _ License No. Phone I TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT P DESTRUCTION ❑ Out of Service Well ❑ ' i PUMP INSTALLATION ❑ SYSTEM REPAIR 1) 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 {-1 Industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing l' C.1 Domestic/Private ❑ Gravel Pack' ❑ Tracy Typo of Casing._~ Specifications U1 Public i-1 Other n Delta Depth of Grout Seal Type of Grout } I I Irrigation Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing-Material &.Depth Depth I Filler Material & Depth y TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADOITIONGI-t DESTRUCTION I 1 INo septic system permitted if public sewer is / available within 200 feet.I Installation will serve: Res r nce 4_ Commercial— Other Number of living units: ^Number of be rooms \� +�"� ' T '• Q� p �" "- Character of soil to a depth of Veal: Water table depth J I SEPTIC TANK. fO Type/Mfg .��C Capacity IV � : No. Compartments PKG. TREATM&� PLT. ❑ "k5, 4 (e.") e as r le, DG Method of Disposal t _.-Distance to nearest: (;2 Well Foundatiory Property-Line C � C ' LEACHING LINEC i No. & Length of lines' Total length/size FILTER BED x n Distance to nearest: ell �4 : Foundation �S� Property Line , ` 261 SEEPAGE PITS Ir!' 'Depth o!s _Sire� Number- �_ SUMPS Ll Distance to nearest: �y Wellf,) !4'S' Foundation Property Line 1 s- ' DISPOSAL PONDS ❑ �� t i/a2E3 Vim_-��'`` C I hereby certify that 1 have p7epared Ihis'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: 1 certify that in the.performance of the work for which this permit is issued, I shall noti employ any person in such manner as to become subject to workman's compensation laws of California:";Contractor's hiring or sub-contricting signature ` certifies the following: "I certify that in the performance of the work for which this permit is issued,-1 shalt employ persons subject to workman's compensa- tion laws of California." !,";• , } -.Y i The applica m call t t all req ad 'r ctions. Complete drawing on reverse side. ' s Signed r_. Title: pate: G OR DEPARTMENT USE ONLY., Application Accepted by Date r Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: - ! t- ! + -77,f 4 _-___.--- ,- f Applicant - Return al'�,,lII copies to: San Joaquin"County,Public Health Servicessb" d16 S1+�t -h".k C "1 •d lyseu' I-r,,ICRttvironmentai>Heal'th� Per-n it%Services b+Pi� ee] 4 •21 •gZ (y +rte¢ S3 M f�er'L� S c,�...j, 495 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ATE PERMIT'N0. INFO + EFS 1124(RE tiwsl En 1624�