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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 EBP:IRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application Is hereby made to San Joaquin County fop�a permit to construct and/or install the work herein described. This application 1s made In compliance with San Joaquin County Ordlmncg No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.,"�/' (gyp ,�t,� �1PP11a/atWk�3 ' Job Address 1 fly � � tr 8"�` '"` City Lot Size/Acreage •� '1 i�� .5 A �.y l.,]4. k k E L Owner's Name Address Contractor ' ; Address License No. Phone TYPE OF WELL/PUMP- NEW WELL ❑ - -- -- WELL REPLACEMENT F) - 13ESTRUCTION ❑ 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 PITS/SUMPS 0 0 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bonom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'I Public f1 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 ❑ Type of Pump M.P. - State Work Done _ Well Destruction ❑ Well Diameter Sealing ahterial. A Depth Depth -- Filler Materiali Depth . 0 .� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR,ADDITIONI DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence!Commercial,_/ iher - Number of living units: 1 Number of//bLeLdrooms Character of tall to a depth of 3,feet: Y^F- Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal o Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 8 Length of lines Tptal length/size FILTER BED, X ,l7 Distance to nearest: Well i.Gil . Foundation j d Property Lira 2. t7i SEEPAGE PITS I I Depth Size Number BUMPS - LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 candies 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 K d.fZ'-,..�. �iV�t....-) - ,\ - Title: 1,..1 A/.��'a. !! Date: DEPA U E ONLY Application Accepted by( Date At Pit or Grout Inspection by Date Final Inspection Dy Date _ Additional Comments: 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 - FEE AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. INFO ill 1Y1UREV.vxm - �/� pa i , cam N bis