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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 2 Q 3 k 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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. i -y Job Address Y City Lot Size/Acreage Owner's Name ' , f ' Address �- r' Phone y'� p ,Jar Phonef&_6-' 1 Contractor f k Address �G �' icer+se fVo. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _FOUNDATION_- -AGRICULTURE WELLS OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial ❑ Open Bottom ❑ Manteca Dia- of Weil Excavation_ Dia. of Well Casing [I Domestic I Private ❑ Gravel Pack Cl-Tracy Type of Casing_ Specifications 1'i Public El Other n Delta Depth of Grout Seal Type of Grout I i Irrigation —.Approx. Depth I+II Eastern Surface Seal Installed by Repair Work Done .� Type of Pump 949,b H.P. _ State Work Done Well Destruction ❑ Well Diameter _ Sealing Material & Depthc�_ llr /v a I Depth Filler Material 8 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence__._.. Commercial— Other Number of living units: Number of bedrooms Q Character of soil to a depth of 3 feet: Water table depth ., SEPTIC TANK. ❑ Type/Mfg Capacity N(P �sW*r PKG. TREATMENT PLT. ❑ r . M I Distance to nearest: Well Foundation Property0�,�� LEACHING LINE Cl No. & Length of lines Total length 677'QAQ,LJ li\3 C°O!.N iY FILTER BED ❑ Distance to nearest: Well Foundation � --Iri6rl�t i 1-i ,DIViSION ENVIR01�MEN i st . j l.J6 SEEPAGE PITS 11 Depth Size Number SUMPS 0 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'Celif6rnia." 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 shall employ persons subject to workman's compensa- tion laws of,California." The applicant nrI for all re uired inspections. Complete drawing on reverse side. ! tcf r Date: 7 I Signed X� -- Title: _ � • _ C OR DEPARTMENT USE ONLY ` Application Accepted,by Date Area f Pit or Grout Inspection by Date Final Inspection by e Additional Comments: Applicant - Return all copies.to; San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaqui Box 2009, Stkh, CA 95201 FEE AMOUNT DUE AMOUNT REMITTE CK RECEIVED By DATE PERMIT'NO. I FO / . EH19-24 IREV.rixsl �^ EH 1L1a