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ENVIRONMENTA.; HEALTH DIVISION 1601 *HAZELTON AVE. , PHONE (209)468 3420 BOX 2009, STOCKTON, CA 95204 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 vork 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. 4 / Job Address �b - �• n� /�� I�/A+ - City� Lot Size/Acreage /- /p' QUQS Owner's Name 7✓ru, s' WIm A-h Address � ,�0/29� Phone RttuviN°' o,3-tS�- Contractor ��F' i V�1 �r Address�1� .� n � 'CLQ License No. Phone TYPE OF WELLIPUMP: NE WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION SYSTEM REPAIR 0 OTHER 0 Monitoring Well boi h DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROPSoi 1 . LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ,y. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS m 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well EacavatIOA Dia. of Well Casing Cl Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications i'I Public f.1 Other fl Delta Depth of Grow Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal installed by �- Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction 0 Well Diameter Sealing Material i Depth 1.1a Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i i (No septic system permuted if public sewer ,$ available within 200 feet.) Installation will some: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK 0 Typo Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wall Foundation Property Line [� SEEPAGE PITS 11 Depth Size Number �( SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereoy certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and ,vires 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 menner as to become subject to workman's compensation Laws of California." Contractor's hiring of sub-contracting signature candies the following: "I certify that m the perlormance 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 It b all required ilnspection Complete drawing ort revs, side. q/ SignedK AV Title: U( 0 StDate: A�IS- f/ FO PA T U E ONLY Application Accepted by Araa Pit or Grout Inspection by Date/ C Z"� Final Inspection b q Additional Comments: `/PiL - KPI /or Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Permit/Services 1601 E. Hatelton Ave., P 0 Boz 2009, Stockton, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CAKS1, RECEIVED BY DATE PERMIT NO. EM t�.�jaEv.,,,,i N 131. 13��. lit 77 6 - /017 y/ 9/ , •w