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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 I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) q-ei ym�,YzL J� Applica n is hereby e, an 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 Publi Health Services. Job Address City ' Lot Size/Acreage Owner's Name Address Phone Contractor Address icense No. hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA EMENT ❑ I DESTRUCTION poDut of Service Well ❑ PUMP INSTALLATION ❑ 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 I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ublic fl Other 171 Delta Depth of Grout Seat Type of Grout —' r\Desttion Approx. Depth I I Eastern Surface Seal Installed by Repaone U Type of Pump H.P. St Work Onnel— Well ❑ Well Diameter -f-d� Sealing Materiel !4 Depth ? Depth -7 Filler Material i Depthot TYPE OF SEP\C WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will ierve: Residence_ Commercial_ Other Z Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size ` FILTER BED ❑ Distance to nearest: Well Foundation Property Line V4 SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 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 m call for all requ• inspe ions. Complete drawing on rse i gd Signed X Title: Date: &° /— FOR DEPARTMENT USE ONLY Application Accepted byDate Area ,ZA' i / Pit or Grout Inspection by Date Final Inspection by ____ DateZlLL,2_(�22 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 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EH 13.24(REV.t i x s ✓^� V U- C EH 11.26 ^ 7