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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 permit to construct and/or install the work herein described. This r application in made in compliance with San Joaqu n County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I E V�/ .L��/a�_ Job Address 2 �'/•�'/ 'wESit/ly_I>.rEldQ r— Lot Size/Acreage e n Owner's Name Address n_ Phone r Contractor dress '' S LamLicense fF Phone TYPE OF WELL/PUMP: NEW WELL ❑ WEL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ YSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ I. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTU ELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA ONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_� Dia. of Well Casing I_I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications — D Public I:1 Other ❑ Delt Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by .. Repair Work Done ❑ Type of Pump H.P. State Work Done_ O Well Destruction ❑ Well Diameter Sea ing Material i Depth Depth Filler Material i Depth \ TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is 11 available within 200 feet.) Installation will serve: Residence _ Commercial Char �\ Number of living units: _ Number of bedrooms_ r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity__ _ No. Compartments PKG. TREATMENT PLT. ❑ Method o1 Disposal e r Distance to-)nearest: Well 0 Foundation d Property Lina LEACHING LINE ❑ No. 6 Length of lines To I length/size V ImC _ FILTER BED ❑ Distance to nearest: Well oundation __ Property Line (.) SEEPAGE PITS I I Depth Sire L It 6 al er SUMPS LI Distance to near L• Well oundation V 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, amd 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 n 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 co!p0Z. 1``, tion laws of California." �,f The applicant must II �pr all raw red inspect ns. Complete drawing on reverse side. � � �� ` Signed Title: a2mi s • IN r1 Date: F DEP= ONLY r Application Accepted by Date��—�'�.�� Area or Grout Inspection by Dat,-2--4-1-2-2- 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, ox 2009, Stkn, CA 95201 �. FEE, AMOUNT DUElAMOUNT REMITTED CK ECEIVED BY TE PE,R/.(MIT'NO. EH 1124)REV.r/xa� INI�( EN 14)d