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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 S Uc .Job Address '"' rt/1/� _ City�l (� L t Size/Acreage Owner's Name r r Irddress _ '"r Phone �2-DzOV ' Z �3.� Contras L�� 1 Address k License No. Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n 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 C7 Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ,--t'Domestic/Private ❑ Gravel Pack D Tracy Type of Casing_ Specifications n - i'1 Public 1-1 Other F1 Delta Depth of Grout Seal Type of Grout \rW1 I Irrigation _.___Approx. Depl I 1 astern :Surface Seal installed by Repair Work Done 0 Type of Pump_ �7��G H.P. 7iy S e Work o GJ" Well Diameter,. ne Well Destruction �� Sealing Material & Depth . Depth Q 1 Filler Material & Depth p _. E OF SEPTIC WORK: NEW INSTALLATION Ii REPAIR/ADDITION I I DESTRUCTION i I iNo septic system permit(a pu lit sewer is available within 200 feet.) Installatio 'I serve: Residence____ Commercial,.Y,,. Other Number of living u Number of bedrooms Character of soil to a depth feet: Water table SEPTIC TANK ❑ Type/M acity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to near e Foundation in i i r i LEACHING LINEo. & Length of lines Total length/size q FILTER BED ❑ Distance to nearest: Well Foundation Properly Line SEEPA PITS I ] Depth Sire "" 'i - - _ - __ Number S S l 1 Distance to nearest: Well Foundation Property Line ISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or licesignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any par .a, such mann r as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fol ing: "I certify t at in the perfor ante work for which his permit is issued, I shall employ persons subject to workman's compensa- tion laws of alifornia." The applic t m require Y plot drawing on� side. Signed Title: Date: FOR DEPARTMENT USE ONLY r y� Application Accepted by 22.fn1X-r,/ _ __- _ __ ___ __ Data - y Area 7 Pit or Grout Inspection by Data Final Inspection by Dat ✓ Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health Services y Environmental Health Permit/Services J{ 445 N San Joaquin, P I1ox 2009, Stkn, CA 95201FEE 1 INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY 9ATE PERMIT'N0. . EH 13-24(Rtv.1/we) EH 1626 L ll C/ 10