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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 477� P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) . 11 Application is hereby made to Sam Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 51+4 and 1862 and the Rules and Regulations of San I Joaquin County Public Health Services.10 Ill City Lot Size/Acreage ' Job Address t S' Phone y3.2 Owner's Name f Address --- r Contractor Addfess e9C ense No, Phone &J L5J r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17 DESTRUCTION ❑ Out of well (- PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO L FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OT WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTIO ECIFICATIONS D Industrial ❑ Open Bottom eca Dia. of W xcavation — Dia. f Well Casing ❑ Mant f7 Domestic/Private ❑ Gravel Pack ❑ Tracy Ty p Casing_ 5pecilications — I'l Public C1 Other f-1 Delta epth of Grout Seal Type of Grout I i Irrigation _Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done — 8 Well Destruction O Well Diameter Sealing Material Depth_ ...-.-.�' Depth r Filler Material Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRJADDITION f I DESTRUCTION No septic system permitted it public sewer is vailabie within 204 feet.) d r installation will serve: Residence— Commercial____ Other, Number of living units: Number of bedrooms §F Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg t Capacity t No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation- -' Props F rty Line 11 f LEACHING LINE Cli1No. & Length of lines Total length/size Y FILTER BED ❑ -Distance to nearest: Well Foundation Property Line z SEEPAGE PITS I I Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Prop6rty 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 t 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 t6 workman's compensation laws of CBlifornia." 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 Califo la." The applicant us call for all required in ct' s. Complete drawing on reverse side. Date: Title: __ 2 �' �� Signed X _ O EPART SE ONLY A tion Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date `� �✓ Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services r^ Environmental Health Permit/Servicesti�ty r _ 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 I i FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMITNO. INFO . EN 13.24 1REV.I/x S) O •_ EN 14.2e _--k