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+t+ 1 F SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made,to San Joaquin County for s permit to construct and/or install the work herein described. This application is made in compliance vith San Joaquin County Ordinance No. 51+4 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ' Job Address F9 - _ City + Lot Size cage d Owner's Name AMf� �� - AddressPhone Contractor SL" r � ,<5-1,Address / '17^�, icense No. Phone i � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT [1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I:] Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Weil Casing i Cl Domestic/Private Gl Gravel Pack ❑ Tracy Type of Casing_ Specifications \ I'1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by �\ Repair Work Done . U Type of Pump H,P. State Work Hone Well Destruction O . Well Diameter Sealing Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 AI ADDITION l I DESTRUCTION I i INo septic system permitted if public sewer is available within 204 feet.] Installation will serve: Residence_ Commercial_ Other J— Number of living units: JL Number of bedrooms r"! Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity MOO - -- No. Compartments PKG. TREATMENT PLT. 0 � Method of Disposal Distance to nearest: Well Foundation =- Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Weil Foundation' Property Line li �r SEEPAGE PITS 11 Depth SizeNumber [5� Cl 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 Home owner or licensed agent's signature certifies the.following: "l,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 Ft 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 required inspections. Complete drawing on reverse side. Signed X Title: r/4'- g "`�`��'`�- - - Date: "-'- FOR DEPARTMENT USE ONLY 1 Application Accepted by Date Ot Z_ Area Pit or Grout Inspection by Date Final.Inspection by Date ` q Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P_Q Box 2009, Stkn, CA 95201 ('1 1FFED AMOU T DUE AMOU T R M TIED ry�K ECEIVED BY t E PERMIT'NO. S^. EH 13.24 tAEV.r n SI EH 14•28 //I/