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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (.209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 M 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. Job Address Pel` City 7 _�T _ Lot Size/Acreage Owner's Name O I� Address Phone Contractor It 5C IV Address dA �'�-' cr License No. Phone TYPE OF WELL/PUMP: NEW WELL 0 LI WELL REPLACEMENT Cl DESTRUCTION Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL _ - OTHER_WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca a Dia. of Well Excavation Dia. of Well Casing C] Domestic/Private ❑ Gravel Pack L1 Tracy Type of Casings I Specifications r I'l Public Cl Other Cl Delta t Depth of Grout Seal Type of Grout I i Irrigation _.Approx. Depth 1 I Eastern Surface Seal Installed by 1 Repair Work Done 0 Type of Pump H.P. State Work Done _ 1 Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION N DESTRUCTION I I�(No septic system permitted if public sewer'is available within 200 feet.) Installation will serve: Residence L Commercial — Other Number of living units: �� Number of bedrooms 1 Character of soil to a depth of 3 feet: g•f. 4 "--" Water table depth - � SEPTIC TANK. ❑ Type/Mfg ` `-.. .LCaps city—tp� No. Compartments 2 I �, Method of Disposal PKG. TREATMENT PLT. ❑ ,. �,i�, y; �.. � � a� Distance to nearest: Well Foundation Property Line p LEACHING LINE No. & Length of lines * �'�I �o length/sae Jul' J FILTER BED ❑ Distance to nearest. Well Foundation f O' Property Line 3o3.S ww•-fv I SEEPAGE PITS ; I I Depth ?Size umber � y`r.✓to(;, 1 SUMPS CI Distance to nearest: Well Foundation Property Line jcac�-fr.+�i 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 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 taws 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required in Complete drawing on reverse sidt e. ti s Signed X p ;` Title:. Date: / " '� "Ey r FOR DEPARTMENT USE ONLY Application Accepted by Date �Y Area I _ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 " FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PER IMIT'ND. INFO .SIL aD /f��e^D 206 �'��.° '�/1 -iF3 ?3-00-7 EH 11.21 IREv.1/w 51 �" EH 14-M