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SAN- JOAQUIN COUNTY PUBUTC HEALTH SERVICES f ENVIRONMENTAL HEALTH DIVISION f 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 L r1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 mad& 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 V 6 s r f L City t� C p Lot Size/Acreage i Owner's Name (te�l7 r leII � Address �gz., 't'� 'P - Phone Contractor t �+rdCi Addressd Lle� . , ��,EL c�� RP_ License NoPhone 1-6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Pr OTHER ❑ Monitoring Well DISTANCE TO NEARESTA,SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 1 AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS R Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing &Domestic/Private `❑ Gravel Pac*7 ❑ Tracy Type of Casing_ Specifications I'1 Public 1-1 Other 171 Delta Depth of Grout Seal Type of Grout I I lrrigation —Approx. Depth I Eastern Surface Seal Installed by - Repair Work Done Y----Type of Pump. a: s H. t! State Work Done . ; E 22 e- Well Destruction ❑ ,Well•Diameter Sealing Material & Depth Depth i� Filler Material & Depth I TYPE OF SEPTIC WORK:' NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is I I d available within 200 feet.l Installation will serve: Residence— Commercial_ Oiher 1 { Number of living units: Number of bedrooms Character of soil to a-depth of 3 feet: ! Water table depth SEPTIC TANK. 0 Type/Mfg J Capacity No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal F Distance to nearest: Well Foundation Property Line � ,.ter -,•,' LEACHING LINE ❑ No. & Lengths of lines Total length/size FILTER BED ❑ Distance to nearest: Well ,Foundation Property Line SEEPAGE PITS s 11 Depth Size Number SUMPS {: LI Distance to nearest: 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."Contractor's hiring or sub-contracting signature certifies the following:fl-csrtify 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 Californi`." The appl_r must call f r all required inspie7ons. C plate drawing on r er/-side, Signed Title: A _.. ..__ Date: fOR DEPARTMENT USE ONLY a Application Accepted by ��AAA � CT ASJJAAQA/ Date a- lArea_.10 r� Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public'Health Services Environmental Health Permit/Services }I 445 N San Joaquin, Box 009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RE LVED BY DAT PERMIT NO. INF may/' . EK 13.71(REV.r i x 5) � EH 117E