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I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, 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. City Lot Size/Acreage I Job Addres l/ V oo�� Address - Phone Owner's Name Ctlntrac ' Address License No. 2 2Z Phone-7 -S-/( TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ Out or ervice well.: Monit ring Well Ej Ks PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER C1 \ 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 k f_7 Industria! C1 Open Bottom ❑ Dia. of Well Casing Dia. of Well Excavation ` f:] Domestic I Private ❑ Gravel Pack7 L] Tracy Type of Casing_ Specifications f"1 Public C1 Other f7 Delta Depth of Grout Seal Type of Graut I I irrigation —Approx. Depth I I Eastern Surface Seal Installed by j Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth ' Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTAL TION I 1 REPAIR/ DITION DESTRUCTION I 1 Mo septic system',permitted if public sewer is available within 200 feet,) Installationfwill serve: Residence Commercial_,,Pther Number of living units: _ Number of oms Character of soil to a depth of 3 feet: Water table depth SEPTIC-TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT'PLT. Cl Method of Disposal- 1r Distance to nearest: Welk Foundation Property Line . ��LEACHIfJG,LINE w,f No. & Length of lines Total length/size K FILTER BED Distance to nearest: Well Foundation �Q Property Line Number SEEPAGE PITS I I Depth Size SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that_the'work will-be done_ in accordance with San Joiquin 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 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 apaln"cilon forMui d inspections. Complete drawing on reverse si T Signed Title: - Date: 2M FOR DEPARTMENT USE ONLYApplicy DateL�Areaorby Da Final Inspection by 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 CASH ECEIVED BY DATE PERMIT'NO. INFO . EH 13.24 IREV.V n$I EH 14-2a