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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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 sS,ervic` C—ges,. �Job Address / t„J_ y A ©u o A�t— - City Lot Size/Acreage r 5: =M Owner's Name. 1 Address Phone e,12 -a ContractorUL16R,- Address License No. Phone TYPE OF WELL/PUMP'. NEW WELL ❑ WELL.REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR C] 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 C] industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation Pia. of We lf Casing Vim' i Ca Domestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing_ Specifications l I'I Public I-3 Other ❑ Delta Depth of Grout Seat Type of Grout I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by , 1 Repair Work Done U Type of Pump H.P. State Work Done _ �J Welt Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth 01, TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION)Q DESTRUCTION 11 (No septic system permitted it public sewer is _.available within 200 feet.) Installation will serve: Residence Commercial Other t Number of living units: _L__-- Number of bedrooms _ Character of soil to a depth of 3 feet: -4 " Y `_J 0. Water table depth' SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ � `T * ., �� Method.of Disposal Distance to nearest: Well Foundation Property Line t LEACHING LINE 0 No. & Length of lines -- Total length/size az> (� FILTER BED ❑ Distance to nearest. Well� Foundation X0 7 Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 foNowing: "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." i applicant mus yr for alGJ� late drawing on reverse side.up Signed � : Date: _4/r/"5 FO DEPARTMENT USE ONLY l G r Application Accepted by Date ` Z" Area Pit or Grout Inspection by Date Final Inspection by !6 Date Additional Comments: l r I 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 REMr77Ep C1< ECEIV BY GATE PERMIT'NO. I !y t CASH NFO . EH 13.24 IAEV. f EH 11.10