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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 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 1802 and the Rules and Regulations of San Joaquin County Public Health Services. )) ' j /odefvel I� City�� Lot Size reage Jab Address Phone 4 22�Al Address Owner's Name — ` Contractor tf+ '<4Q 9,✓�'G/�"`fkAdd Address 0` 12 Y72&K? v License ffo. � Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION C} Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS INTENDED USE TYPE OF WELL PROBLEM AREA Casing �f' CONSTRUCTION SPECIFICATIONS Dia. of#Wail �Q Well Industrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Specifications - Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I'l Public +. 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I 1 Eastern Surface Seal installed by Repair Work Done 0 Type of Pump H p State Work Done_ f Sealing Material & Depth Well Destruction ❑ Well Diameter Filler Material &`Depth Depth TYPE OF SEPTIC WORK: NEW INSTAL I 1 EPA1Ri DDITION I 1 DESTRUCTION I I (Noavas septic le withinsystem m rented if public sewer is Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: I SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKC. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE �, No. & Length of lines Total length/size � a-- t FILTER BED n Distance to nearest: Well_5 �'�" Foundation Property Line — SEEPAGE PITS l-1 Depth Size )(/0 K Number PS . Ot-- Pro Line Distance to nearest: Well ��"_ Foundation— Property DISPOSAL PONDS 'L! 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, 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, { 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 taws of California." L The appficant must ca or�red inspections. Complete drawing on reverse 'derj�T Title: �2�C�L�1��GFr✓ - Date: Signed FOR DEPARTMENT USE ONLY — ti, .�.,d Date k�� Z-0 -�[Z Area Z' Application Accepted by Pit or Grout Inspection by Date Final inspection by Date L�-ZO -JZ. I Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Sox 2409, Stkn, GA 95201 FEECK RECEIVED BY DATE PERM17'NO. INFO AMOUNT DUE AMOUNT REMITTED CASH . EK 13-14 MEV.r,ll 51 °c 185z`� R L� 11-�3 .9 X12-3,"ZV� EH 1416