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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 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. S6 Job Address `-r 1 IQCity Lot Size/Acreage Q31_ ID39 Owner's Name r� ' Address33 E Phone Contractor ._A.,P,4dress License No.Q.f�;"hol Phone 40 1-1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT R DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C7 \ 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 Pack El Tracy Type of Casing_ Specifications i'I Public M Other f1 Delta Depth of Grout Seal Type of Grout ✓�J�\ I I Irrigation —Approx. Depth I I Eastern 'Jurface Said Installed by Repair Work Done U Type of Pump H.P. State Work Done I Well Destruction © Well Diameter Sealing Material 8 Depth Depth: t Filler Material.B_Depth �— TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is r available within 200 teet.i Installation will serve: Residence--Commercial•r.._Other Number of living units: ! Number of bedrooms Character of soil to's depth of 3 feet: P Water table depth SEPTIC TANK. ❑ Type/Mfg _ Capacity- PKG. apacityPKG. TREATMENT PLT.Ll - MCIIiff PPI Distance to nearest: Well Foundation Property } n- H 1 LEACHING LINE -0 No. $ Length of lines ' _ _ T_otal lenh5AN J0A0 nl ^T FILTER BED 0 Distance to nearest. Well Foundation _ rFAj T!; t —' �IV� ! �ViHLi Crit ilc .r; .Ji'� SEEPAGE PITS 'I I Depth Size Number 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 employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the folly : "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 ia." The applican call for all req i d inspectio Complete drawing on ravers de. Signed TiNe: Date: - �q F DEPARTMENT 5E ONLY I Application Accepted' y Date Area Pk or Grout Inspectio by Date Final Inspection by 14tDate �`Z 14 Z Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services i E Environmental Health Permit/Services 445 N San Joaquin, Box 2009, Stkn, CA 95201 E i FEE AMOUNT,DUE AMOUNT REMITTED CK RECEIVED BY PATE PERMIT'NO. INFO 1 r r EH19.24tREV.+/NSI :�_ FH 1428 /1!