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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, STOC%TON, 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 1862,and the Rules and Regulations of San Joaquin County Public Health Services 30-707 S,_ CWA?_1s1Le 1 City� Lot Size/Acreage Job Address rr Phone ~ Owner's Name f� Address i /j Contractor _T Address 1h License No"'t Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION Cl out of service Well ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR [y7' OTHER ❑ Monitoring Well ❑ ; DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing Cl Industrial VG C)pan Bottom O Manteca Dia. of Well Excavation Specifications [-1 Domestic/Private Gravel Pack ❑ Tracy Type of Casing_. i"1 PIic fa ther I"1 Delta Depth of Grout Seal Type of Grout Irriaation Approx. Depth I i Eastern Surface Seal Installed by (� � H.P. ,State Work Done Repair Work Done U Type of Pump Sealing Material 6 Depth Q Weil Destruction ❑ Well Diameter Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTION I I available within 200lootI[No septic system tled if public rawer is `^ V J � Installation will serve: Residence— Commercial— Other n Number of living units; Number of bedrooms ` Character of soil to a depth of 3 feet: Water tIon ft SEPTIC TANK ❑ Type/Mfg Capacity No. C t r Metho I PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line 5 S 931MAN LEACHING LINE Cl No. & Length of lines Total lengthlsiz FILTER BED Cl Distance to nearest: Well Foundation Property Linep�SERVICEJ I SEEPAGE PITS 11 Depth Size Number if 1� SUMPS GI Distance to nearest: Well Foundation Property Line ^ r 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 Home owner or liven d 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 para i such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies the folio i : "I ce ' that in t performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Cal In." l The applicant u t call f a requ' nspections. Compiete drawing on re ers ide. a Signed Title: Date �`J ORXEPARTMENT USE ONLY �+ Application Accepted by Date 6 `3 Area 071 l Date Final Inspection by Date Pit or Grout Inspection by k Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT N0. INFO EN 13.24 IREV. 51 'P_0 14-28 T { r