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I APPLICATION N COUNTY PUBLIC HEALTH SEVICES LV RONMENTAL HEALTH DIVISION-- 445 N S JOAQUIN , PHONE (209)468-3420- R 209)468-3420 P O -BU% 2009, STOCKTON , CA 95201 �' PERMIT EXPIRES 1 YEAR FROM DATE ISSU`' -7 FX ��}} (Complete in Triplicate) 5 ,ANY,# ,# County for a permit to construct and/or install the work herein described. This encs with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address�65 / Af.-nor-� (a✓'T City 5�0Yl Lot Size/Acreage QD 64JI fft CD Address /Z- // ^''e- `'�G'ti.�,�.c{O 95w fir; Owner's Name /4Gt �'1 � o � 3 �� b A J 7Phone y1 /�//P Qu<<rry L4?4e.0 Contractor ASSOC10-"feS Address �7 S• License NoC fV+ TYPE OF WELL/PUMP: DISTANCE TO NEAREST INTENDED USE F1 Industrial [1 Domestic/ Private ('1 Public I I Irrigation Repair Work Done ❑ Well Destruction O NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Ll Out of Service Well LI PUMP INSTALLATION 0 SYSTEM REPAIR C) OTHER, Monitorings Well SEPTIC TANK IV-14SEWERLINES ± Zo DISPOSAL FLD. N14 PROP. LINE ± 3V FOUNDATION t� �AGRICULTURE WELL iY� OTHER WELL_LYC� PITS/SUMPS NA TYPE OF WELL ❑ Open Bottom ❑ Gravel Pack 1-1 Other —, Approx. Depth Type of Pump Well Diameter _ Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Manteca Dia. of Well Excavation ❑ Tracy Type of Casing _ 6i:4 4" 'V n Delta Depth of Grout Seal ZO I I Eastern Surface Seal Installed by H. P. __-- State Work Done _ Sealing Material & Depth Filler Material & Depth Dia. of Well Casing 2=__ Specifications – Specifications Type of Grout & c E 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 _ Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK O Type/Mfg PKG. TREATMENT PLT. ❑ Distance to nearest: Well Other Water table depth _ Capacity No. Compartments Method of Disposal Foundation Property Line it LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I 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 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 for all r it inspections. Complete drawing onreverseside. Sig Title: FOR DEPARTMENT USE ONLY p Y L Application Accepted by Date / Area �p � Pit or Grout Inspection by Dat,4 Final Inspection by �' ��i Date Additional Comments: Applicant - Return all copies to • EH 13.21INEV. rinsr EH 1426 San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95 O /� O OUNT REMITTED RECEIVED BY PERMIT'NO. / FEE INFO AMOUNT DUE AM CASH