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SAN_ JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE {209)46$-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 -application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. - - [///r7 //may j ] A ,L Job Address IM-L rjfa4N City Lot Size/Acreage a4y"g- Owner's Name �G Addressy� 4 - Phone Contractor \C f%'A O"' Z� Address 'TOY r ?k License No. .6 Pill, --TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT - DESTRUCTION o Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR OTHER.e7 Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK I!L,4? ^ SEWER LINES DISPOSAL FLD.Lr^ PROP. LINE 'LOd FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r Cl Industrial 0 open Bottom D Manteca Dia. of Well Excavation � Dia. of Well Casing �O �omestic/Private Gravel Pacy ❑ Tracy Type of Casing._ 1rC Specifications dq VI Public fa Other �r� n Delta Depth of Grout Seal — S O Type of Grout e�IkCN� I I Irrioation t 00-Approxi Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump ', - H,P. State Work Done Sealing Material & Depth Well Destruction ❑ Well Diameter s' Depth I _ ' "Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I 'REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will.serve: Residence Commercial_ Other. • ' _ s r Number of living unite: Number of bedrooms Character of soil to a depth of 3 feet: � Water table depth e a SEPTIC TANK. ❑ Type/Mfg I Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal f Distance to nearest: Well foundation Property Line'!-=— LEACHING ine•"'LEACHING LINE D No. & Length of lines Total length/size , ` FILTER BED ❑ Distance toinearest: Well Foundation Property Line \ SEEPAGE PITS 11 Depth I Size Number SUMPS Ll Distance to nearest: Well foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this appfication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and F rules and regulations of the San"Joaquin County r Home owner or licensed agent's signature certifies the following: "I certify that in the performanpe of the work for which this permit is issued, I shall not employ any person in such manner as-to become subject to workmen'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." 1 "�. `� `•' r The applicant must call for all-'required inspections. Completed"drawing on reverse side. Signed G!r/V � r Title: ' Date: FOR DEPART.MENT.•UrSE,;ONLY, Application Accepted by Date v g ` Z Area \ W r Fi al Ins !O 12�GI Pit or Grout Inspection by Date Inspection by Dat Additional Comments: r �' S L If Applicant - Return all copies to: San Joaquin County Public Health Services r ! . S 5-!57 Environmental Health Permit/Services -�ofi,a 445 N San Joaquin, P_O.Box 2009,. Stkn, CA 95201 tr'1 r z te,_ .r FEE AMOUNT DUEi AMOUNT REMITTED CK - EdEIVED BY D E PEAMIT • EH 13-2I(REV.t In SI /b