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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. JobAdd,,,, LAJAME-fZ City Lot Size/Acreage Owner's Name UA N Addresses g I Phone 3 S Contractor1/a(' y Address ^ License No. ('A S 3 Phone r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION f.'3 Out of Service well ❑ PUMP INSTALLATION CEJ, SYSTEM REPAIR ❑ OTHER C 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 C-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Gestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 1'} Public i-1 Other n Delta Depth of Grout Seal Type of Grout I i Irrigation ......_ Approx. Depth ` I I Eastern Surfa a Seal Installed by Repair Work Done ❑ Type of Pump %�Q H-P. f State Work Donelz� 4l1 Welt Destruction ❑ Well Diameter Sealing Material & Depth �iltir4Cl Depth Filler Material & Depthrs � TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION E I DESTRUCTION I I (No septic system permitted if public sewer is L1. available within 200 feet.1 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 }vim SEPTIC TANK._ . _ - ❑-_Type/Mfg- Capacity No. Compartments PKG. TREATMENT PLT. D Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L3 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation• Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 Sen 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 m all for all required inspections. Complete drawing on re rse sr Signed ( Title: S Date: Z R D RTMEfYT USE ONLY f�7Z 111' Application Accepted by Date + 2-- Area Pit or Grout Inspection by Date Final Inspection by xkjDate /5J•'" 1 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT OUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO • EH 13.24{REV.i/R S EH 14•Ia /�J