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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 mede_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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. G/ Job Address _�—RLL -�—�-,V r City dl� Lot Size/Acreage pCGC/".01f s+�� e /7�/�j ��L � /��/�{� °9 93 d 3 Owner's Name l! � Address �T�` - Phone Contracts /V tow rJ Address S License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ,Cl DESTRUCTION LI out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR.q OTHER ❑ Monitoring Well L� 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 Q.,) D industrial ❑ Opan Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t t Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications W I'I Public EI Other fl Delta Depth of Grout Seal TYPO of Grout `. I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump , tia. H.P. - State Work Done v&, if p ,�,g �Szajaye Well Destruction ❑ Well Diameter Scaling Material 8 Depth Depth Piller Material i Depth v C� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I I (Noseptic system permitted if public Bawer is available within]W lest.) Installation will sena: Residence_ Commercial_ Other Number of living units:_ Number of bedrooms Character of wit to a depth of 3 feat: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments yyy PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line A� LEACHING LINE ❑ No. 0 Length of lines Total length/size IAF FILTER BED ❑ Distance to nearest: Well Foundation Property Lim tl SEEPAGE PITS 11 Depth Sime Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby comity 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 applicant must c//a��ll'',,fo/////fJJrr all[re�quiredd^ins�ppections. Complete drawing on reverse side. Signed X_ ` Z Title: nynfh.A� Date: U FOR DEPARTMENT USE ONLY Application Accepted by � Date - Area Ph or Grout Inspection by Date Final Inspection b Dete4 -. Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Enviroame atal Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFOCA.SW . EH 13-A IREV.rIasi �R7r EH 14-M , J4 Q/ C� O