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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 Sean 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. Job Address p City Sn^-doh Lot Size/Acreage Q s,26C Owner's Name d f I n RK I mr, Address 85 Phone —8 �S 6W Contractor Address License No. Phone TYPE OF WELUPUMP: NEW WELL ❑ WELL REPLACEMENT i-1 DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well CJ 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 Cl Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_. Specifications I'I Public Cl Other 17 Delta Depth of Grout Seal Type of Grout 1 1 Irrigation — Approx. Depth I # Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth ` Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIRIADDITION I 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: _ t___ Number of bedrooms_3 C;ICA Character of soil to a depth of 3 feet: Water table depth S 42 SEPTIC TANK ❑ Type/Mfg Capacity 15U • No. Compartments PKG. TREATMENT PLT. ❑ & ti Method of Disposal1 \ Distance to nearest: Well I:Z Foundation Property Line 9y; ,r LEACHING LINE L"l No. & Length of fines �a+L g-� ' `i ne.S Total length/size ' FILTER BED 0 Distance to nearest: Well Foundation R' Property Line _AM' SEEPAGE PITS DCI Depth r��r Size ill. A 1(�jl 4!,� (Number.rs2 SUMPS Ll Distance to nearest: Well Foundation. Property Line _ DISPOSAL PONDS ❑ E 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: 1 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 appiica fus all for all requ ed ins tions. Complete drawing o rse side. C J Signed Title: - Date: OR RT T USE ONLY Application Accepted by Date 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 0 Box 2009, Stkn, CA 95201 INFE AMOUNT DUE AMOUNT REMITTED �K REC D 9Y DA7E PERMIT'N0. • EH t3-24(REV. EH 74-2e / �/