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u 4� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 gg - - P PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I� (Complete in Triplicate) M 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 coatpliance with San Joaquin County Ordinanc No. 549 and 1802 and the Rules and Regulations of San Joaquin County Public Health Services. 00 . Job Address d / City ..K of Size/Acreage 1 Owner's Nam Address Phone Contract Address icense No��`/0 -Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION 0 SYSTEM REPAIR K OTHER El 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 Cl Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing �QDomestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications C1 Public la Other f"1 Delta Depth of Grout Seal Type of Grout - I I Irrigation —Approx. Depth Eastern Sqqol5a Saul Installed by CieQ Repair Work Done X Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIRlADOITION i I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.I v Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I t Water table depth SEPTIC TANK Cl Type/Mfg Capacity � -"""- No. Compartments PKG. TREATMENT PLT. ❑ r t Method of Disposal \\ + Distance to nearest: Well Foundation "Property Line i LEACHING LINE ❑ No. & Length of lines —Total length/size FILTER BED 0 Distance to nearest: Well Foundation .� Property Line e SEEPAGE PITSI I Depth' t Size Numbar, SUMPS LI Distance'to nearest: Well Foundation Property Line- DISPOSAL POND8 ❑ -t "'"��'"`; J 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,work man'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 persona subject to workman's compensa- tion laws of Cal' e I i The ap i nt must call r all required ins ons. mplete drawing on rev e. IQ Signed % -Title: _ -� S- -T Date: CPOr FOR'DEPARTMFNT E ONLY- Application Accepted by _ r_- 1�. �� s,,n1@+! __ Date$ Area 2 Pit or Grout Inspection by Date Final Inspection by TLS 42 l."'t Date Additional Comments: J Applicant - Return all copies to: San Joaquin County Public Health Services \ ' Pseviroomental Health Permit/Services 445 N San Joaquin, P Box 2009, Stkn, CA 95201 CK WINFO AMOUNT DUE AMO NT REMITTED CASH ED BY DAT PERMIT'NO. r EH 13.24 WV.t i x 51 t o-oI EH 14-26 j