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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOA UIN PHONE ONE (209)46$-3420 P 0 BOM 2009, STOCKTONi CA 95201 w PERMIT EMPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for e permit to construct and/or install the work herein described. Th application is made in compliance with San J aquin County Ordinance No, 549 and 1862 and the Rules and Regulations of San I Joaquin County Public Health Services/.. Jeb Address _- Z . t! City -st� Lot Sfze/Acreage "+ r Owner's N,,a{{m��e �� / p / Address Phone Contractof(O`-'a &IL C.r:_ ress (f4 �e No. xaPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i FOUNDATION f AGRICULTURE WELL OTHER WELL PITS/SUMPS } INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T C1 Industrial ❑ Open Bottom; ❑ Manteca Dia, of Well Excavation {Iia, of Well Casing (a Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications } F1 Public Cl Other F1 Delta Depth of Grout Seal Type of Grout f_" I I Irrigation _-App(ox. Depth l I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump I H,P. State Work Done Well Destruction ❑ Well Diameter Sealing Material A Depth Depth l Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION E I DESTRUCTION I eplie system permitted if public sewer is t .r 1 available within 200 lest.) m Installation will serve: Resi�jence commercial Other Number of living units: l Number of bedrooms Character of soil to a depth of 3 feet: i — - Water table depth SEPTIC TANK ❑ Type/Mfg. -J.` Capacity___L_ No. Compartments PKG. TREATMENT PLT-C] Method of Disposal Distance to nearest Well Foundation Property Lina I � LEACHING LINE C1 No. 8 Length of lines 'Total length/size FILTER BED ❑ Distance to nearest: Well ... Foundation Property Line �l SEEPAGE PITS 11 Depth 1: Size r Number SUMPS , 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS �❑ 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 rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies 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 the following: " ca 'fy that in the pertor nce of the work for which this permit is issued, 1 shall employ persona subject to workman's compensa tion laws California.' 1 t I The applicant call or all eq ad specti ompl a drawing o verse tie, r l 3 Signe Me: `- 9 , Date: X t � f0 DEPARTMENT USE ONLY �h —ApplicatirnAccepted bWy^� `,. c;`i�.,�:'r ��^� Date Area -- Pit or Grout Inspection by s� Date Final Inspection by Date Additional Comments: s I • Applicant -Return all copies to:----San--Joaquin-county-Publ-tc-Health-Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y DATE PERMIT NO. INFO CASH EK 13-24 • EH 13.24 IREV. rinsr { J. r � .r/