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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 I� _l PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) j 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. 544 and 1862 end the Rules and Regulations of San Joaquin County Public Health Services. X00 Lot Size/Acreage Job Address ty f Owner's Name I UkJkx& -- Address Phone i 936 amr Fiit . Address t�J1 License No. Phon z Contractor ` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR l OTHER ❑ Monitoring Well n F. 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 ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Weft Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications lit 1-1 Other F1 Delta Depth of Grout Seal Type of Grout Irrigation _.Approx. Depth 1 Eastern Su ce Seat Installed by BI 1 Repair Work Done f�Type of Pump�— H.P. State Work bone Well Destruction © Well Diameter Sealing Material & Depth �# Depth Filler Material & Depth Q je TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ! DESTRUCTION I I Mo septic system permitted if public sewer is C available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms -_-_character-of--Poil-to_a-depth-of_3-feet: _ __- --- ---1Nater-tabte_dept SEPTIC TANK. ❑ Type/Mfg Capacity No. y t te. m a PKG. TREATMENT PLT. Cl Matho f Distance to nearest: Well Foundation Property Li m f i LEACHING LINE ❑ No. & Length of lines Total length/size I �f FILTER BED ❑ Distance to nearest: Well Foundation Prop 'inn k kEr.l F_ els S (� SEEPAGE PITS 11 Depth Size - Number r SUMPS Ll 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 accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County r Home owner or licensed agent's signature certifies the following: "t certify that in the performance of the work for which this permit is issued, I shall not employ any pers i such manner as to beco subject to workman's comps sation laws of California." Contractor's hiring or sub-contracting signature ` certifies the foil i "I ce that in the ormanca of the work for.which is permit is issued, I shall employ persons subject to workman's compensa- tion laws of Ii o is.,. I The appli mtail f r t c tons. omplete drawing on ve si Signed Title: Data: _FOR DEPARTMENT USE ONL Application Accepted by Date v Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant -'Return all copies to:- San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, Sox 2009, Stkn, CA 95201 S- FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIY:N0. INFO �EH 13-24 IREV.7 i n 51 its-, EH 71-se _