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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. 5h9 and 1$52 and the Rules and Regulations of San Joaquin County Public Health Services. t I Job Address Z&XZ_11l, .441412 _F—Z&/ LA! _ City + Lot Size/Acreage i Owner's Name A264--9 -4.-li2&-NSEA1 Address Phone 2 Contractor-. - . L 00:D Address Ia L License No, ",4 X74 Phone -3 7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well Ca 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 n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing fa Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications FI Public fa Other fl Delta Depth of Grout Seal- Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material S Depth TYPE OF SEPTIC"WORK: NEW INSTALLATION I I REPAIR/ADDITION)CT DESTRUCTION I I INo septic system permitted.it public-sewer is available within,200 feet.) Installation will serve: Residence Commercial_ Other 1 Number of living units: __L Number of bedrooms 32 Character of soil to a depth of 3 feet: e L Water table depth SEPTIC TANK ❑ Type/Mfg E,ti S. �Xle- Capacity No. Compartments" PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ` LEACHING LINE P1 No. 8 Length of lines =:f1gi Total length/size FILTER BED C7 Distance to nearest: Well SOS Foundation Property Line 3 SEEPAGE PITS 11" Depth Sire 1l Number SUMPS LI Distance to nearest: Well /om Foundation --S'D' Property Line S� DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt 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 must call for all required insPections. Complete drawing on reverse side. Y SignedCos.G4 r' . - � Title: Date: w FOR DEPARTMENT USE ONLY Application Accepted by Date A rea, it r--Grout Inspection by Data Final Inspection by fjete° ,� :z Additional Comments: Applicant - Return all copies to: San Joaquin County Pil Health Services r Environmental Health;Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED INFO CASH CK RECEIVED 9Y DATE PERMITNO. . EH 13-24 IREV.I r n Sr �- EH 14.28 32 Z •� �J - -- e� I