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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION J 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009 'STOCKTON, CA 95201 I/` J 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 8 Job Address !/ r CL i Cit ize/Acreage Owner's Name Address GL. Phone Contrac r ss40-is o0c License Nolb?,� 73 Phone TYPE OF WELL/PUMP: NEW WILL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U 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 [.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications f"1 Public C1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation -.Approx. Depth` .I!I Efsstern Surf co Seal Installed by Repair Work Done Type 61 Pump H.P. State Work Done Well Destruction © Well Diameter Sealing Material & Depth 116 V Depth Filler Material & Depth TYPE OF SEPTIC WORK: -NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is -I ", available within 200 feet.) Installation will server Residence_ Commercial_ Other Number of living units: Number of toms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0- ypa/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: We Found on Property Line s. LEACHING LINE Cl No.:& Length of lines Total length/size FILTER BED ❑" Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth S`. Number SUMPS 0 Distance to—nearest,—7- a#- ` Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this applicAon and that the work will be done in accordance ith San Joaquin county ordinances, state laws, an rules and regulations of the an,Joaquin County Homeowner or Iicen agent signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any peso n such me or as to become subject to�alb man's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foll ing:."I ca at in the pert man a of rk for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of 9fillforni The applica t a f 11 r plate dr mg on rove Signed X Title: Coe PARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection Ipy Date Final Inspection by Date 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 REMITTEDinC SH RECEIVED BY DATE PERMIT'NO. ,[✓ �j� . EH13.211REV.tsl IAO i� v _j � -✓ � �� a EH 71-I6 �•/