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�—' SAN J0%gaIN COUNTY PUBLIC HEALTH SEhwoliCES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 L 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County}Public Health Services. C. Job Address Z! �L- �' �1�'}i.iL_Trt,! S t . City �1�1iLTLgN► Lot size/Acreage Owner's Name �L +�Z 1F�T�i Address t L+3 �-�3A 1•�1 lUc,�1�! Phone Z,-.,O7- � - G L (f Contractor Address ?' Li "- tzy'1 -1- bI(—Z License No. 3%:;(P .�i 1 Phone Si e>�"07`iL TYPE OF WELL/PUMP: NEW WELL 2 WELL REPLACEMENT i1 DESTRUCTION O Out of Service Well O PUMP INSTALLATION Z SYSTEM REPAIR O OTHER O Monitoring Well g_ DISTANCE TO NEAREST: SEPTIC TANK N/ _ SEWER LINES 7 3,y ' DISPOSAL FLD.N/A PROP. UNE ALA FOUNDATION X7:4 AGRICULTURE WELL —&IIA OTHER WELL_AL. PITS/SUMPS -41 . INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial O Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing Z- ~ Ni Domestic/Private Z Gravel Pack G Tracy Type of Casing_ PVA- Specifications I.1 Public 1-1 Other r. Delta Depth of Grout Seal J Type of Grout I I Irrigation _Approx. Depth 11 Eastern Surface Seal Installed by K%�L1tL �JZ t.v� Repair Work Done i.J Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Z Sealing Material i Depth Depth Zs Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer Is available within 200 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 ^`v\ PKG. TREATMENT PLT. ❑ Method of Disposal �\ Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, 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 signatur 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 applicant As i all f I rep ed inspections. Complete drawing onKly_rse side. Signed X Title: Date: f t /Z 9 lS 3 FOR DEPARTMENT USE ONLY (� Application Accepted by Date Area c Pit or Grout Inspection by Date �Z ZL Final Inspection by �"' Date v Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services uv r— I f Savironmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE 9 INFO AMOUNT DUE AMOUNT REMITTED CASH CK 8 RECEIVED BY DATE PERMIT NO. �` O EM13-24IREV.iiM51AW EM 11.20 III G 1