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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 I YEAR FROM DATE ISSUED (Complete in Triplicate) N Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This i application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San r Joaquin County yPublic Health Servicce,+s�^.0, � c Job Address . L � �L�*'�`� `� rJ city � Lot Size/Acreage 1 ry Owner's Name ._ Address S c�n Phone XA Contrattor 6 Address �J71t� fes. License No Phone 2?-4-9-11-1 4�• TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ! ..y. SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FI.D. 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 Well Excavation Dia. of Well Casing ,wi5omestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'l Public 13 Other n Delta s Depth of Grout Seal Type of Grout I I Irritlation —.Approx. Depth I I Eastern Surface Seal Installed by ��! Repair Work Done U Type of Pump H.P. State Work Dona V Well Destruction ❑ Well Diameter Sealing Material & Depth _ r-AP-C /V4' a) Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/A'DDITION-I-I�DESTRUCTION i-I.•INo septic system permitted if public sewer is ��qq available within 200 feet.) Installation will serve: Residence_,._. Commercial_ Other R 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. Compartmentsyy t PKG. TREATMENT PLT. ❑ J Method of Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size _ FILTER BED ❑ Distance to nearest: ^Well Foundation Property Line 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 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 manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature certifies the fallowing: "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 applicant muAt 11 for all r aired ins tions. mplate drawing onr7rs;4e. �y 2 Signed Title: _ _ Date: 14 :7 *r—91 2- a7s PARTMENT USE ONLY C20:5.A.- r Application Accepted by ,.�r.�.rv.M�- - Date t� Arse r Pit or Grout Inspection by Date Final Inspection by Date 1 , 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 RECEIVED BY DATE PERMIT'N0. INFO « EH 13.741AEV.r/nsi I' fQ � I b� ISH 1/-20 iii ` s