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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) I f Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This j application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San N Joaquin County Public Health Services. Job Address �k ,g �- y - ��_�_ City A Lot Size/Acreage Owner's Name i 9� ) 1&#eR.A19Z Address Phone Contractor--4-X-14 ry Address tam 21A�2 Z r License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F.1 DESTRUCTION o out of Service Well -❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 3 OTHER O Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C:1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications C] Public 1-1 Other f 1 Delta Depth of Grout 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 p� Well Destruction .❑ „Well.Diameter,, Sealing Material & Depth W -- -•---- Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I, INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence'k Commercial_ Other Number of living units: -/— Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity_ r No. Compartments PKG. TREATMENT PLT.❑ sj '- Method of Disposal Distance to nearest: Well 66* , ndation-�l Property Line f ..f LEACHING LINE No. & Length of tines Total length/sire - �T FILTER BED (A Distance to nearest: Well roundation A21gorl Pt6perty line 14 � SEEPAGE PITS I I Depth A Size_ X f��Cr� Number C SUMPS 15e Distance to nearest: Well Property Line_��__ ��s;� Foundation DISPOSAL PONDS ❑ } 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: "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." The applicant must call for all rerad inspections. Complete drawing on reverse side. f Signed X Title: ._t'� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area Z t Pit or Grout Inspection by Date Final Inspection by A I Data Z Additional Comments: i 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 FEE AMOUNT DUE AMOUNT REMITTED' CK REGEWEpYBY DATE PERMIT NO. INFO CASH RV . . EH13.24 MEV.i/A% EH 11440