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i + SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 Coun y Public Health S rvIces. Job Address City t�+Lj 2 Lot Size/Acreage -F-err�/ 6+�e_fq �47_0 n i�soNem a�� Address'''] G1Phone O UX uyb License No. Phone TYPE OF WELL/PUMP: NEW WEL`L � WELL REPLACEMENTIF DESTRUCTION 0 Out of Service Well ❑ I PUMP INSTALLATIONS SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK // SEWER LINES DISPOSAL FLD. PROP. LINE E FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS 11 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 C1 dustrial ❑ Open Bottom 15-Manteca Dia, of Well Excavation Dia. of Well Casing I mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications j Il Public Cl Ol ier Depth of-Grout-Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern 4 Surface Seal installed by ,. I Repair Work Done 0 Type of Pump H.P. State Work Da Well Destruction ❑ Well Diame er �______ Sealing Material & Depth Depth. Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I 1 INo septic system permuted it public sewer is { available within 200 feet.) r Installation will serve: Residence_ Commercial_ Other `l Number of living units: Number of bedrooms r _t Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:+ Well Foundation Property Line LEACHING LINE C) No. & Length of.lines Total length/size FILTER BED ❑ Distanceto nearest: Well Fou idwion V� Property Line SEEPAGE PITS I 'I Depth Size rNumber SUMPS -.—.:--...,--_--__G1--.Distance-to-nearest:. Well- —,---- _Foundation - ..Property-Line-=----- ---- DISPOSAL PONDS ❑ r 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 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 shall employ persons subject to workman's compensa- tion laws of Cal' rnls." , The applica t calf fora ins tions. Complete drawing on rev e side. q/--/, / Sign X Title: Date: 77 7l FOR DEPARTMENT USE ONLY j c Application Accepted by Date Area 0 f Pit or Grout Inspection by Date Final Inspection by Date Additional 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 INFO AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED BY DATE PERMIT'NO. . EH114.20 I,EV.,,Kei S ro`a 9�J-7 -- EH 13.24 t