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SAN _~AQUIN COUNTY PUBLIC HEALTH VICES 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 a perm t to construct and/or install the work herein described. This application la made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Se Ices. Job Address -13 7-5--it) -`'R City r Lot Size/Acreage D _ Owner's Name �� Address J `tis' Phone J�ap,' �' D ((�}}'''--�� A _ Contract�",ti�'A lddress 1. �, U�'x7�7 "-4! License 1Noa3gZz(P Phone -� e TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT f i DESTRUCTION Ll Out of Service Well n PUMP INSTALLATION ❑ SYSTEM REPAIR Li OTHER ❑ Monitoring Well C7 _ 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 11 Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private U Gravel Pack ❑ Tracy Type of Casing___ _ Specifications I I Public fa Other f-1 Delta Depth of Grout Seal _ Type of Grout I I Irhgauon _ Approx. Depth I I Eastern Surface Sedl Installed by 1� Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth ler Material & Depth -' TYPE OF SEPTIC WORK: NEW INSTALLATION IEPAIR/ DDITION DESTRUCTION ! 1 (No septic system permitted d public sewer is ,/ available within 200 feet.) IX Installation will serve: Resrnce _ Commercial �Qther Number of living units: Number of be rooms 5 (� _ Character of soil to a depth of 3 feet: �� s �� _ Water table depth �" SEPTIC TANK ❑ Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ d Method of Disposal Distance to nearest: Well Foundation ___ Property Line r _ i I_ LEACHING LINE , No. & Length of lines — SO (Total length/size--7___ _ FILTER BED CI Distance to nearest: Well !�C 4 Foundation (0 4 Property Line 4 SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well _ Foundation Property Line DISPOSAL PONDS Cl 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: "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 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." The applica ust cal` VII quired inspections. Complete drawing on reverse` Date: DONL�( c Signed X Title: � �- FOR DEPARTMENT USE ONLY Q� Application Accepted by`71401 4 - tit Oats�7l _U —�� Area Pit or Grout Inspection by Date Final Inspection by / Date�Z Additional Comments: TTT Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 VVJ FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BV DATE PERMIT-NO. \ EH 13 24 rinJ� ,� -d �/y ° G �,� ��g-�Z �2--3e7 z EH l4Qe