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SAN '%eAQUIN COUNTY PUBLIC HEALTH .,.dVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-34203t.� 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. Mw � !)fes-�7 Pflcu-,L c 1v` -e33-03q Job Address Z 13 `�' r l t Ate? N� � ST City '� Zk-7'IVN-.J Lot Size/Acreage Owner's Name r—g, (5 5�t is z� Address 2 �0 ✓r i�41,11 A'N'N St Phone Contractor L K- t�-� tAddress 342,1 License No. 31=ke Z-qI Phone51tz -42>4 -.G'7792- TYPE C7? LTYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Li DESTRUCTION K Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK ;' 3,20 SEWER LINES DISPOSAL FLD. NIA_ PROP. LINE _141-- FOUNDATION NIA AGRICULTURE WELL N/A� OTHER WELL_A4eA - PITS/SUMPS bj INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Zk ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation AJ I& Dia. of Well Casing Cl Domestic/Private 'N Gravel Pack ❑ Tracy Type of Casing__Syc— Specifications &A- FI Public I-1 Other rl Delta Depth of Grout Seal tV Type of Grout I I Irrigation ?:C—)Approx. Depth I I Eastern Surface Seal Installed by N 1 Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Z t Sealing Material & Depth In - SAttr. M.tx - 70 FT Depth 12-0 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.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms C Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, 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 applicant ust call,f. II r uirad inspections. Complete drawing on r verse side. Signed X Title: _ Date: FOR DEPARTMENT USE ONLY �j Application Accepted by // Date [)2/�FF—rJ Area Pit or Grout Inspection by Dater f 3 Final Inspection by / ` - 0'� � m _. Additional Coments: / Z, f Applicant - Return all copies to: San Joaquin County Public Health Services FY2,?O?Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C K iRECEIVED BY DATE PERMIT'NO. ,` INFO ASH /� . EH 13.21 IREV. i x sr C) U !� aV/ ; EH 7/.2e W� Ci