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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-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]pServices. Job Address �?�f �� _"L0__274� W��irV Lot Size/Acreage 7 Owner's Name " kZiAddress Phon Confracto(46wL -- Address _&1 ksalmlk �.. License NAII—V66 Phoneme TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ but of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR CST OTHER p Monitoring Well L3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LlIndustrial ❑ 0 n Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing W"Domestic/Private L'GraveI Pack L7 Tracy Type of Casing_ Specifications i'1 Public f-1 Other I l Delta Depth of Grout Seal Type of Grout I 1 Irrigation / _.Approx. Depth l I Eastern ace Seal Installed by {� Repair Work Done Id Type of Pump b_ H,P. State Work Done�oej C 'V Well Destruction ❑ Well Diameter1 sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No 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. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, I-) Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/sfie AYMENT FILTER BED ❑ Distance to nearest: Well Foundation Prope,% i 12 SEEPAGE PITS 11 Depth Size Number `l SUMPS Ll Distance to nearest: Well Foundation -. PEb t"OL4QU4N COIJNl DISPOSAL PONDS ❑ PJt3LIC HF-M- r S-H I hereby certify that I have prepared this application and that the work will be done in accordanc-I tian'Yoaqun 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 perso in ouch manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fol Ing: ";cerlity that in the pe mance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of orrtla." The ap ica ust c aired ;tions. Complete drawing on ve side. Signed Title: Date: FOR DEPARTMENT USE ONL �fe Application Accepted by Date Pit or Grout Inspection by Date Final InspectionZ- Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFOEs AMOVNT DUE AMOVNT REMITTED CK RECEIVED BY DATE PERMIT'NO. EH 1 -21 IREV.tiw6i EH 114.26