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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 I-A. P O BOX 2009, STOCKTON, CA 95201 � r• `" 1' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 5�;��p T 2 6 (Complete in Triplicate) F f�,4fc42% 'pAt!//V Application is hereby made.to San Joaquin County for a permit to construct and/or install the w6442Jr�j scz d rsfThis application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and R� n l�ifi§an Joaquin County Public Health Services. lvi lQjv • �� Job Address City hot Size/Acreage Owner's Name _^ Address 13 Zai tri . f/��eGa �� C hone .4sj' — F Contractor Address Gt✓ /-mo i License No.`C��Phon Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR V__� OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE - - - - - FOUNDATION ~ AGRICULTURE /AV L `QTHER VtiIECL PITSTSUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C} Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C.) Domestic/Private ❑ Gravel Pack7 LJ Tracy Type of Casing_ Specifications f"I Pu iic Cl Other C"1 Delta Depth of Grout Seal Type of Grout i rn9ation —Approx. Depth Eastern Surface Seal Installed by Repair Work Done Type of Pump 1 H.P. u -_— State Work Done ` Well Destruction ❑ Well Diameter Sealing Material i Depth Depth----Awl Filler Material i Depth W TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.l ` Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to s 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 Ll No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number k SUMPS •1=1—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 pars in such manner as to becomes bjsct to workman's compensation laws of California." Contractor's hiring of sub-contracting signature certifies the f Ilo Ing: "1 Certify th t in the perfor, nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of ornla." The applica t ust call for II fired in6pec' ns. amplete drawing on r or Signed Title: Date: � � _ FAR DEPARTMENT USE 0A Application Accepted by Date <© Aq z Area lea Pit or Grout Inspection by Date Final Inspection by Date LL 4 L Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin,,PO Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTEDCKSH RECEIVE!BY DATE PERM.INO. INFO � • EM 13.24 IREV. /n 51 J`�� q'J^-0-0 6D �8 Q EN t4.26