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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 PERMIT EXPIRES I 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 withSanJoaquin County Ordina ce No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. - t Job Address � Q 00ZCity Lot Size/Acreage Owner's Name 3 Address ✓ Phone Contractor Yac� ��l_(� Address A ��License t�1� _,r Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION ❑ Out of Service Well Cl 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 f-1 industrial ❑ Open Bottom El Manteca Dia. of Weil Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'l Public Cl Other f-1 Delta Depth of Grout Seal Type of Grout I I irrigation _ Approx. Depth ( Eastern S.UlLace Seal Installed by OF Repair Work Done ,ice" Type of Pump H.P. State Work Don 4� Well Destruction ❑' Well Diameter Sealing Material & Depth Filler Material & Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDIT15N I I DESTRUCTION i I lNo septic system permitted it public sewer is available within 200 feet.) ("� Installation will serve: Residence._....._ Commercial— Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r Method of Disposal Distance to nearest: Well Foundation Property Line N.. n LEACHING LINE ❑ ',No. & Length of lines Total length/size FILTER BED Ll iDistance to nearest. Well ,Foundation Property Line \ a SEEPAGE PITS 11 Depth Size Number SUMPS Cl Distance to nearest: Well— ° Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the.work will be.d f e in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County 1 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 laws-of California." Contractor's hiring or sub-contracting signature certifies the following: "I cenify 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 California." 4 The appli ust al for all required inspe ' ns. Complete drawing on revers side. Signed X -Title bate: FOR DEPARTMENT USE ONLY Application Accepted by _l �wA M r � ~-�. Date - 0R_1:)-SAA— Area Pit or Grout Inspection by - DateLL� +Fine I-inspection by -- - Data r" Additional Comments: "* s Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Healt ermit/Services 445 N San Joarqu 0 Box 2009, S n, CA 95201: INFO AMOUNT DUE AMO NT REMITT CK RE C VED 9Y DA;k PERMIT'NO. EH 13.24IMEY.1,85) EH 14.28 �f r