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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES II ENVIRONMENTAL HEALTH- DIVISION '�445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 � I L PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j` (Complete in Triplicate) Application In hereby made to S.11.Joaquin County for a permit to construct and/or i�n�yeetall the work herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1851 and the Rules and Regulations of San Joaquin County Public Health Services.clef ryl 51 and Job Address o'"L �� City hot Size/Acreage how II Address Phone Owner's Name 1 i 1�}r))��4�� Contractor r+i Address C- License tai Pito TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ 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 \ n industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation _ - Dia. of Well Casing j VDemestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications C1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout 1 i I Irrigation Approx M Depth L I Eastern Surface Seal Installed by Repair Woik Done � Type of Pump H.P. -C -- State Work Dane ��'� p' Sealing Material & Depth Well Destruction ❑ Well Diameteyr Depth �p Filler Material_& Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i 1, DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence T.� Commercial— Other (� Number of living units: Number of bedrooms ,p�� Character of soil to a depth of 3 feet: Water table depth t,w SEPTIC TANK- 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT..❑ !I " "_ r Method of Disposal a Distance to nearest: Well Foundation Property Line . If LEACHING LINE ❑ No. & Length of tines Total length/size (a FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth II Size Number SUMPS LI Distance to nearest: Well Foundation t Property Line? DISPOSAL PONDS ❑ �I 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 rnanner 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 ap M u call for"all required ' spections. Complete drawing on r rse side. Signed X Title: - e -- Date: 244 Ih FOR DEPARTMENT USE ONLY Application Accepted by —a��^I� 01 �I��i `fid Date L Area Pit or Grout Inspection by II Date Final Inspection by Date f Additional Comments. II II Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services t` 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 AFEEli AMOUNT DUEI� AMOUNT REMITTED CASHRECEIVED BY DATE PERMIT'NO. EN 14.20