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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION \• 3f � 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 Puubbliic Health Services. L Job Address CY` ® 6 S• U S T I N rZ d City STk Lot Size/Acreage _ r S 22-y zs Owner's Name IS 4 C% `" FAa�'""a Address �1 [77/ .S It4y•T�;.�,r /?z/ h',ear� Phone Contractor Gli> ,:I+f rn, Address � Q CS tlX jam/?t�� S1 License No. Phone Y6,' 6� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION ❑ 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 �'��! n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public 1:1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation ` Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material b Depth Depth Filler Material & Depth J TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION IT DESTRUCTION I I INo 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: Water table depth SEPTIC TANK O Type/Mfg f r.••- h�-f Capacity 7 n. No. Compartments ^� PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ,�1" No. & Length of lines L/c A Total length/size FILTER BED 0 Distance to nearest: Well Sty- Foundation S�� Property Line S SEEPAGE PITS IX Depth Size 3 3• Number r SUMPS LI Distance to nearest: Well /�° Foundation It: Property Line u 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 no 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 California." The applicant must call for II required inspections. Complete drawing on reverse side. Signed X Title: Date: F9 ENT USE ONLY I Application Accepted by Ao Date Area ) 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 FEE AMOUNT DUE AMOUNT REMITTED I CK 0 RECEIVED BY DATE PERMIT'N0. INFO CASH a . EH 13.211REV.iixsr R EH 11.26 'a