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i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 l�rB P 0 BOX 2009, STOCKTON, CA 95201 4% 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 t work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and t Rules and Regulations of San Joaquin County Public Health Services. Job Address I� City Lot 'Size/Acreage a I� Q Owner's Name ` Address /Of Phone II` y N 13.3 r9 Contraclor Address ° License No. Phone TYPE OF WELL/PUMP: '� NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Cl PUMP`INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial C] Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications o , i'1 Public is Other n Delta Depth of Grout Seal Type of Grout I i Irrigalion —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type 0 Pump H.P. State Work Done Well Destruction ❑ Well Dfiameter Sealing Material & Depth Depth 1M Filler Material pth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION i r�DESTRUCTiONK INo septic system permitted if public sews( is C\ r o available within 200 feet) Installation will serve: Residence Commercial_ Other (��\ Number of living units: _ Ib Number of bedrooms Character of soil to a depth of 3 feet: Water table depth vw SEPTIC TANK ❑ Type/Mfg Capacity 0 No. Compartments PKG. TREATMENT PLT. ❑ I� ^� -7 ,�Method of Dispp Distance to nearest: Well _ Foundation->`---- Property Line-__4__9__. LEACHING LINE ❑ No!I& Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation d Property Line SEEPAGE PITS 11 Depth Size Number SUMPS ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ IN 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-mann*-asto-becorwsubject to wis7kman's compensation laws of California."_Contractor's hiring or sub-contracting signature certifies the following: "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 The applicant must ]call fol allr I)read inspections. C plele drawing on reverie side. Signed K'_I I.7__ 'f Title: 146114 Date: / t FOp DEPARTMENT USE ONLY Application Accepted by �A_� *��. •mpy Date Z Area S Pit or Grout Inspection by I� Date Final Inspection b Date Additional Comments: I� Applicant - Return all�jcopies to: San Joaquin County Public Health Services I Environmental Health Permit/Services dl 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFO FEE AMOUNTIIrpUE A_MOUMT REMITTED K RECEIVED BY DATE AERMI7'N0. . EH 13.24 11tEV,r/H5) // EH 14•20 0-0 , / t