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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 �1 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) " Application is hereby made to Sam 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 1662 and the Rules and Regulations of .San Joaquin County Public Health Services. f] jj..��,+�,� Job Address (,3-1 Se S�T R D City Sr�r�"' Lot SLze%Acreage 6 Owner's Name VE!/YCt5 x-13rRLA-11 Address 5 W#t 7 l Phone t-$�b U n�o�►T oSo if 3 — �'!7 Contractor NoA Address License tV � Phone TYPE OF WELL/PUMP: NEW WELL Q WELL REPLACEMENT C7 DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION 9�/ SYSTEM REPAIR ❑ 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 C-1 I ustrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private 0 Gravel Pack L7 Tracy Type of Casing_ Specifications T I'I Public Ll Other n Delta Depth of Grout Seal p Type of Gout t I Irrigation —.Approx. Depth i I Eastern5u ace Sedi Installed by Repair Work Done 0 Type of Pump � H,P. _ State Work Done 11 49a -Well Destruction O Well Diameter Sealing Material & Depth [ ed,LLAG;�(L_ Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I 'REPAIR/ADDITION I I DESTRUCTION I l jNo septic system permitted if public sewer is available within 200 feet.) _ Installation will serve: Residence Commercial— Other _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: 4.. Water table depth -- SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ ,i. _- Method of Disposal Distance to nearest: Well Foundation Property Line r - LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Welt 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 performanci of the work for which this permit is issued, I shall not employ any parson in such manner as to become subject to workman's compensation laws of Cslifornia:',Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." k The applicant must call for all required in16, Complete drawing on�ver side. z �j Signed7k1r- Title: �,[7 � lQ Date: ✓� f DEPARTMENT USE ONLY t Application Accepted byt:�1/�� +� ` _ Date Area 2-1 ; I Pit or Grout Inspection by Date Final Inspection by Date Additions! Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. d r EH 13-2/trtt:v.1 Q in7i A, +/�� 7 EH 1411M 1�+ r I 12 F-2—S0221