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SAN JOAQUIN COUNTY PUH AC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 { PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is here made to San Joaquin Count for permit to construct and/or install the work herein described. This pp by q Y pe € application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County blit Health Services. �' y Job Address - City s�L. C.r Lot Size/Acreage in Owner's Name/` t>�D dress L ` �" Phone �j��j � �- G v G Address;` I l A/_1 -P License N3 d Phone Contralto - TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well ❑ I PUMP INSTALLATION ❑ , SYSTEM..REPAIR OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK.m ' x SEWER LINES DISPOSAL FLO. PROP. LINE - FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS k n industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing )9ZQomssflc/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public i-1 Other I-1 Delta Depth of Grout Seal Type of Grout I i Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done t< Type of Pump J " H.P. _ 6 State Work Done Well Destruction• ❑ Weil Diameter Sealing Material & Depth 'F t Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITiON'I I DESTRUCTION I k {No septic system permitted if public sewer is �.. available within 20D feet.) Installation wily serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: - Water table depth f SEPTIC TANK."" ❑ Typ0Mfg.. " I � y � Capacityr � No. Compartments � yl PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total-length/size------- � r FILTER BED . ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS •" �• 11 Depth Size' ' � ` � � Number � I 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 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 I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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 app?171 ust c for all required i pections. Complete drawing on revel&e.,side. !M Signed Title: _v �� _� Date: i FOR DEPARTMENT USE ONLY u-p Application Accepted by -` Date Area O Pit or Grout'Inspection-by Date Final Inspection by Date V— Additional Comments: �n Applicant - Return all copies to., San Joaquin County Public Health Services `y1 Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMITNO. + EH17.21 1REV.r y x 5 ' B Q `� EH t4•2e • �r�U