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SAN �AQUIN COUNTY PUBLIC HEALTH IVICES ENVIRONMENTAL HEALTH DIVISIOV 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 application is made in complisnce vlth San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Lyo3 uUta be%%,V City Lot Size/Acreage Owner's Name JL,n_V Address CK'S U.AAA o.xvaS K[1 Phone Contractor aw. _ /l. WLAccress Z4%ZS E License No. LSL�_Phone - 7 TYPE OF WELL/PUMP: NEW WELL 39 WELL REPLACEMENT 71 DEuSTRUCT,1t0�4 ❑ Ouy of Sery ce Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ -1 V OTFTEF;.X L-li•_Monitoring Well 1f 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 tt ❑r' Industrial ❑ Open Bottom u Manteca Dia. of Well Excavation fs Dia. of Well Casings ` ', , �, `� Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ �Y I- Specifications—�II4 PI Public 77(I�Other 1�Delta Depth of Grout Seal � TCpe of Grout 3s.a. I I Irrigation Approx. Depth I Eastern Surface Soul Installed by /.�:•.��c-a 4 cy Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearesr. Well Foundation Property Line LEACHING LINE ❑ No. & Length of fees Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 appl a m at 1 for required insWborts. Complete drawing on reverse side. /n Signed Title: Date: Date: FOR /� j� R DEPARTMENT USE ONLY --y7- �7�1^ Application Accepted byte"' rc/ Date ` ' V / CL Area Pit or Grout Inspection by Date Final Inspection by 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 I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. • EM 1124 IREV.1/xsi 11 L �Pi �2 EH tame V 0u'((