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.... SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �f f EPIVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I` (Complete in Triplicate) N, Application Is hereby made.to San Joaquin County for a permit to construct and/or inatall 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 Sart Joaquin County Public Health Services. Job Address c City r�CL. Lot Size/Acreage P p I'1 ) Owner's Name 1[Jr i; j-412 a _ Address Phone Contractor q-i AddressJLF 6C 6J 9�? tr�^yo (0 i License No. __J •�1� phone TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom ❑ Manteca Die, of Well Excavation Dla. of Well Casing C_l Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications I'I Public I'1 Other n Delta Depth of Grout Seal Type of Grout I I irrigation _Approx. Depth l I Eastern Surface Se installed by Repair Work Done 0 Type of Pump H.P. ' State Work Done (Z/r a r` Seals Haterial i Well Destruction ❑ Well Diameter �- Sealing. Depth Depth Filler Material i Depth k; TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTION l I Mo saptic syslem permitted if public rawer is --- .j :::.j 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. ❑ T e/Mf YP 9 Capacity No. Compartments =, PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line =i i SEEPAGE PITS I I Depth Size Number SUMPS L•I Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ;;..._i 1 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 z1 rules and regulations of the San Joaquin County :j Home owner or licensed agent's signature cenifles the following: "I certify that In the performance of the work for which this permit Is issued, I shall not Ci employ any person In such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature r, certifies the following: "I certify that in the performance of the work for which this permit Is issued,I shall employ persona subject to workman's compensa- tion lawn of California." The applicant must 11 for zue,irIns ct Complete drawing an reverse side. ) Signed Title; Date: -.4 6 E3 FOR DEPARTMENT USE ONLY Fi Application Accepted by / Date Area Pit or Grout inspection by Date Final Inspection by Date bit/l f yj is Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 448 N Ban Joaquin, P O Box 2009, Stkn, CA 95201 1 FEE AMOUNT DUE AMOUNT REMITTED INFO CK RECEIVED BY CASH GATE PERMIT'NC. `J EH1J•71IREV.IIM61 =� 25 EH 4.26 `ItJ i