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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �J 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 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. Job Address p " a �` oZ /^D A„� 7 City� Lot Size/Acreage Owner's Name 19�>� Address & ,V/ 1'/'�&Sy,, . ,9Phone e2 —6 L16 O Contractor t" e C / Address ' +L• 67CoG/ �� Lkcense No. 62� Phone SW13 5� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT-171, DESTRUCTION t of Service Well 0 " Monitors Well PUMP INSTALLATION ❑ _� F- ._$YSTEM REPT IR ____OTHER ❑ ❑ DISTANCE TO`:NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �r FOUNDATION AGRICULTURE WELL - OTHER WELL PITS/SUMPS i iNTENDED'USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i-] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F� Domestic/Ptivate ❑ Gravel Pack ❑ Tracy /Type of Casing_ Specifications j Il Public Cl Other I Delta Depth of Grout Seal' ""'^" ' "" Type of Grout I I Irrigation _ g Approx. Depth 1 I Eastern Surface Seal Installed b t Repair Work Done U Type of Pump H.P, State Work Done _ ' Wexestruction Well Diameter �— Sealing Material Depth �_ f war lei�� a Depth Filler, Material Depth F TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I O1ESTRUCTION I I (No septic system permitted it public sewer'is I _ •, . -...-available withinVOO feet.) 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 R Distance to nearest:,- , Well Foundation Property Line �r t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED-' ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1 ) Depth 'Size Number 1 SUMPS LI Distance to.nearest: Well i Foundation Property Line DISPOSAL,'PONDS ❑ I r I hereby certify that I have prepared this application and that the work will be done in accofdance with San'Joaqu n county ordinances, state laws, and rules and regulations of the San Joaquin County k Hama owner or licensed agent's signature.certifies the following: "i certify that in the performance of the work for which this permit is issued,.1 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 work man's:compensa- tion laws of California." The applicant st call for all requir ins tions.1 Complete drawing on reverse side, , Signed X--me Title: G �d Date: OR DEPARTMENT_ USE ONLY.7 Application Accepted by Date ' Area Pit or Grout Inspection byDate Final Inspection b -Si pate r ., ' Additional Comments: ,�,`.e ,;,. _-v, Applicant - Return all copies to: San Joaquin County Public.,Health Servtcesr t 'x IS Environmental Health Permi tser.v_ices •r ; p v 445 N San Joaquin, P 0 Box 2009, Stkn, GA '9520i--. _. INFO" AMOUNTiDUE -.tet. AMOUNT-REMILfED CK CASH RECEIVED BY -- -DATE . EH tI3-24 MV.�"s) •YJ� 3 .. 1 V v 4-26 EH I t