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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r work Application is hereby made toanan ce Joaquin gancJoaquinoCounr a Py Ordinanceermit to nNoru5k9ct aand o1862sand the eRules and Regulations dof Sans application 1s made in comp Joaquin County Public Health Serrv�iccg&•,r c City Lot Size/Acreage Job Address �fq `) ,�„�E LRPhone Address Owner's Name -tic ease-No__ _ Phone— - Contractor. 44Z -� �'✓-� �—Address put oP Service Well m NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ F TYPE OF WELL/PUMP, Monitoring Well �3 f SYSTEM REPAIR.Cl OTHER 0 PUMP INSTALLATION D SEWER LINES _-�� DISPOSAL FLD. PROP. LINE I DISTANCE TO NEAREST: SEPTIC TANK PITWSUMPS FOUNDATION ��— AGRICULTURE WELL OTHER WELt INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing l ❑ Open Bottom Q Manteca Dia. of Well Excavation i t- Industrial Type of Casing_ Specifications [.f Domestic I Private Cl Gravel Pack ❑ Tracy Type of Grout Q� it Deha Depth--of-Grout',Seal-— I'1 Public, I-1 Other T - i Approx. Depth t I Eastern Surface Seal Installed by I I Irrigation — State Work Done ' H.P. of Pump Repair Work Done L7 TYPa Sealing Material & Depth_ 0 Well Destruction ❑ Well Diameter Filler Material i Depth Depth r_ TYPE OF.-5EP71C WORK: NEW INSTALLATION REPAIRlADDITION'l Iw DESTRUCTION I I afvailablerwthin 200 feetc system it4ed if public sewer is t Installation will serve: Residence-L— Commercial Other E Number of living units: _/_ Number of bedrooms p+ti. Water table depth ems, Character of soil to a depth of 3 feet: No. Compartments Capacity ' SEPTIC TANK ❑ Type/Mfg � - Method of Disposal PKG. TREATMENT PLT. ❑ Property Line Distance to nearest;rte Wei — Foundation• � -`--� r' o& Lengthof lines, G F Total length/size LEACHING LINE P_—No. FILTER BED n Distance to nearest: ., Well Foy ndation� Prope F Q 2 :sire - Number SEEPAGE PITS I-1 Depth SUMPS Property Line — Distance to nearest'., Well �CjkJe .� foundation� s 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 "I certify that in the performance of the work for which this permit is issued, ! shall ur e Home owner or licensed agent's signature cenifies the following: {, to become subject to workman's compensation laws of California." Contractor' employ any person in such manner as s hiring or 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 campensa• tion laws of California." I The applicant must tail for al requlr d inspections. Complete drawing on reverse side. i i- f / - � Tide: —� _ Date: ' Signed - �" a , FOR DEPARTMENT USE ONLY Date Area Application Accepted by 2 Z " by . Date. Final Inspection by Date Pit or Grout Inspection 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 f FEE ' AMOUNT DUE AMOUNT REMITTED CK RECEIVED f3Y' DATE PERMIT•N0. INFO . EH 53-24 IAEV,I I K 51 , EH t�•2e _