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i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ` ENVIRONMENTAL HEALTH DIVISION ' 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 NQ ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fqZ (Complete in Triplicate) Cie)- % Application is hereby made to San Joaquin County for a permit to construct and/or install the Work herein described. This ;T`D 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 s �` City Lot Size/Acreage 2AQX M.0 Owner's Name ddress J'd 4,e, _ Phone Contractor Address License No. .2� r�9 Phone `" d TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well 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 r- n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f.] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_'� �` "" Specifications -4-1 Other ❑ Delta —A- - Depth of,Grout.-Seal. s ' Type of Grout f r! I I litigation _..Approx, Depth I I Eastern Surface Saul installed by W Repair Work Done U Type of Pump ; H.P. -State Work Done — Well Destruction ❑ Well Diameter Suing Material & Depth _ - Depth r Filler Material & Depth t ,TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRIADDITION I ! DESTRUCTION iNo septic system permitted if public sewer is \ ; available within 200 feet.1# Installation will serve: Residence_ Commercial ( Number of living units: Number of bedrooms Character of soil to a depth of 3 feel: ` Water table depth CCa� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ' PKG. TREATMENT PLT. ❑ i -`:,If Method of Disposal Distance to nearest:` Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size � Y FILTER BED C). Distance to nearest:I Well Foundation Property Line �_. SEEPAGE PITS 11 Depth'-- _2% Size . Number Q , SUMPS Ll Distance to nearest: * Well "Foundation Property Line r DISPOSAL PONDS ❑ 1 + I hereby certify that I have prepared this application ind that the work will be'done in accordance with San Joaquin county ordinances, state-laws, and rules and regulations of the San Joaquin County '' 1 Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this peimi[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." j The applica ust cap for all-r u inspections:Complete drawing on revd'rse side. # ■ - { Signed X i Title: � �'�k,(4� _-_ Date:_ 'a FOR DEPARTMENT USE ONLY r 9 Application Accepted by Date': 1__ `_ Area Q Pit or Grout Inspection by Date Final Inspection by Date 3 t Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services EnvironmentalHealthPermit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C1C RECEIVED BY PATE, PERMIT'NO. INFO CASH - . EM trz,(REV. 5) r va Baa /078 f-`f-9 3 73- 4D E11 14.20