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I SAN JOAQUIN COUNTY PUBLIC"*HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)465-3420 P 0 BOX 2009, STOCKTON, CA 95201 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 work herein described. This II 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 171 7 l Q City /f Size/Acreage Owner's Name/!�� ;1,4 Of Address T �L�Lf,} /�t�p Apt one Contractorli /'_ [ � �_ ---Address License No-r�a Phan 4—,5�fx� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION i=1 Out of Service Well D PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 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 L1 Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing Y-Domestic I Private ❑ Gravel Pack7 C1 Tracy Type of Casing_ Specifications I'1 Public El Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depths i II Eastern Sur a Seal Installed by Repair Work Done Type of Pump H.P. State Work DoneG— Well Destruction Cl Well Diameter Sealing Material & Depth ' Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION f I REPAIR/ADDITION I i DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ 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--_ No. Compartments PKG. TREATMENT PLT. Cf ~~ --Method-of-Disposal " Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest. Well Foundation. Property kLine �•�,-4 f S - t I 1 I SEEPAGE PITS r 11 Depth Size- f Number r SUMPS V LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accor4ance.wilh.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 taws of California." Contractor's hiring or sub-contracting signature j 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 C ' is." ,1 The ap ' ant must all for all required inspections omplete drawing on rev r side'.' s Signed X Title: / Date: ,,�� DEPARTMENT USE ONLY Application Accepted by 4iw _ _ __ Date ZT_� Area Z Pit or Grout Inspection by - .D a .Final lnspectian by. Data 124 Al Additional Comments Applicant - Return all copies to: San Joaquin Cutiy'Public Health S`ervdces Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 _&�t2 , 'A OUNT DUE AMOUNT REMITTED CASH RECEIVED BY DAJE PERMIT'No. I EM 13.24 IREV.r i n ss s EH 14•2a