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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 Joaqu n County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. _��w� ( y � 4 G �/Y` �. t �7 I Jqb Address � --� r��! City � Lot Size/Acreage i { Owner's Name Address Phone ContractorAddress License No� Phone 1,4f 7 TYPE OF ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Mlonitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO, 'LINEPROP. /INE I a. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE: OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,0 n Industrial ❑.Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casings [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I') Public l-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by 1 - Repair Work Done O'' 'Type of Pump H.P. iz State Work Done # Well Destruction ❑ Well Diameter Sealing Material & Depth r Depth • Filler Material 5 Depth t r TYPE Of SEPTIC.WORK; 'NEW INSTALLATION Ji REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is ? available within-200 feet.) Installation will serve: ResidenceEl Commercial_�,_ Other Number of living units: Num'berofbedL&poms J Character of soil to a depth of 3 feet Water tabledepth ' i SEPTIC TANK. [ Type/:M_ fg Capacity Q No. Compariments PKG. TREATMENT PLT.❑i t Method of Disposal ' Distance to nearest: Well fe"tAZ4undation Property Line f ' LEACHING LINE ❑ No. & Length of lines g Total length/size 7 p FILTER BED ❑- Distance to nearest: Well _ undation — Property line RO ff t SEEPAGE PIT I I,� Depth Size SLG Number S LI `Distance-to nearest:- ^I'Well u dation C2 Property Lina--D.-Z2 R DISPOSAL PONDS ❑ k � 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 cenifies the following; "I certify that in the performance of the work for which this permit-is-issued-1 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 I certifies the following: "I certify that in the performance of the work for which this permit is issued, I,hail employ persons subject to workman's compansa- tion laws of California." The applicant TuslAall for all rrqu ed inspect' Complete drawing on reverse side. 4 SignedTitle: _ � Data: F DEPARTMENT 11SE 0 LY Application Accepted by •Date2— Area o Pit or Grout Inspection by Date Final Inspection by ^ Date � i 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 RECEIVED BY DATE PERM17'N0 . EH 13.21(REV.r i w s; ti� y EH 14-20 r V - �' L `