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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 IP O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1i1 (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. S 4J r r��f,� A+ city q a e ` Cit M�1}r t`Te.�' Lot Size/Acreage r /7 G y_ Job Address � y Owner's Name �4 � � � �'Ir Address S��' � `— Phone -79 . 7 04C6 Contractor - e-1— r- - Address License Pio. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 Cl Industrial ❑ Open Bottom M Manteca Dia. of Well Excavation Dia. of Well Casing f:} Domestic/Private 0 Gravel Pack7 L1 Tracy Type of Casing__ Specifications I') Public I:1 Other fl Delta Depth of Grout Seal Type of Grout � I I Irrigation —Approx. Depth I ) Eastern Surface Seal Installed by Repair Work Done U Type of Pump l H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ( REPAIR/ADDITION 1 i DESTRUCTION i i lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence &f<Commercial Other t Number of living units: Number of bedrooms 16 Character of soil to a depth of 3 feet: -T L Water table depth SEPTIC TANK f$-***Type/Mfg Cdref`i . Capacityl d a No. Compartments Z PKG. TREATMENT PLT. ❑ / 0 / Method of Di Plesal Distance to nearest: Well 304 t'Foundation _[ O Property Line J LEACHING LINE 0�r No. & Length'of lines 3 L in-5:K '�' a dotal length/size C d FILTER BED ❑ Distance to nearest: Well 3 O Foundation 1 ! _._ Property Line 6r__6 I 1 r' � SEEPAGE PITS I ) Depth ) Size Number SUMPS LI Distance to(I'nearest: Well Foundation Property Line DISPOSAL PONDS ❑ i i 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 I rules and regulations of the San Joaquin County it or which this permit is issued, l shall not Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work f employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature l cartifies 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 applican t c for uired inspections. Complete drawing on reverse side. Signed X Title: ,f- S e ___ Date: — FORD RTMI N1,edSE ONLY Date �= ea Application Accepted by 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 445 N San Joaquin, P 0 Box 2009, Stkn, CA 9520 FEE AMOU DUE � AMOUN ^REMITTED CK ECEIV BY ATE PERMIT'NO. IN �. . EH 13-24(REV.vsl EK 11-2a //I/- )