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� SAN JOAQUIN COUNT? PUBLIC HEALTH SERVICES ENVIRONMENTAL FEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 r / 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. Joh Address City TAc Lot Size/Acre age Owner's Name Address 5�2X750 r/,%- Phone Conttactot .�. ;,- Address 2 _/r r.�AOrL License No* Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT D DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION �t 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel•Pick ❑ Tracy. .� Typeof-Casing -'� • ' ` . - Specifications X1 Public El Other �... �l Delta-� Depth of Grout Seal- Type of Grout 1 I I Irrigation —.Approx. Depth t II Eastern Surface Sedi Installed by Repair Work Done Type of Pumper H.P. / State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is M available within 200 feet.I Installation will serve: Residence_ Commercial___-, Other Number of living units: Number of bedrooms :V: Character of soil to a depth of 3 feet: Water,table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line j L LEACHING LINE 4 ❑ No. & Length of lines Total length/size �p FILTER BED I=I Distance to nearest: Well ! Foundation Property Line'' SEEPAGE PITS v� I I Depth Size _ Number SUMPS 1El Distance to nearest: Well Foundation Property Line DISPOSAL. PONDS ❑ " f 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 y 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 at 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 applicant call r all required inons. Camp drawing on r se side. speot Signed Title: Date: /,s Z4 cfOR DEPARTMENT USE ONLY a Application Accepted by Date 2 Area d Z Pit or Grout Inspection by Date Final Inspection by Date v Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK# t RECEIVED BY DATE PERMIT'NO. . t:N,3.2,iREY,,,KIS)EH �, t425