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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 r � P 0 BOX 2009, STOCKTON, CA 95201 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 made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health 3ervi rn /j i Job Address . city Lot Size/Acreage 2��_ siOwner's Name d Address Phone 43 /Z_ ContractordDii�j�','- _A*d11"2J Address 414xr' License No. yg_3—�25 Phone TYPE OF WELL/PUMP: NEWWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Kell C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION .1 _ AGRICULTURE WELL OTHER WELL PITS/SUMPS "ILINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS in industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ei Domestic/Private Ci Gravel Pack ❑ Tracy Type of Casing_ Specifications I'l.Public t C7 Other `Cl Delta "Depth of Grout Seal -Type of Grout- 11 rout-11 Irrigation _.Approx. Depth I I Eastern Surface Seal Installed.by Repair Work Done �0 Type of Pump H.P. State Work Done its Well Diameter Sealing Material +lr Depth 1 -^ - B'�y Weil Destruc ion c LP AJPG-V 41"91 /�j/Depth Filler Material 3 Depth 6�'f3�71�r% TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is i I 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: I Water table depth SEPTIC TANK 3 © Type/Mfg , _ Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal ` v Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Lengthrof lines Total length/size FILTER BED ❑ Distance to nerarest: Well Foundation Property Line 1 SEEPAGE PITS 11 Depth .f Size Number I SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 persori in such manner as to become sutilect to workman's compensation laws of California." 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, I shalt employ persons subject to workman's compensa- L tion laws of Calif rnla." I The applican t calLfpr all req d ins tions. Complete drawing on reverse de. Signed . Date: FOR DEPARTMENT USE ONLY Application Accepted by W.� Data Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: I Applicant " Return all copies'Pto: 'San Joaquin County Public Health Services } Environmental Health Health Permit/Services 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 r FEE AMOUNT DUE MOUNT REMITTED SH RECEIVED DATE PERMIT'NO. INFO J� ,w . EH 13.24(REV.%/a sl r7/- 3�" - EH 14.20 VVV --- 4.V4.WVV f