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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION li 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application:ls 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. Job Address 11 gia City 4 t LCT t `Q,Ljot Size/Acreage 6ao, PhoneOwner's Name Contractor le� Address License No. Phone, TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE �l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDEDJIUSE TYPE OF WELL PROBLEM AREA CONSTRUCTION.SPECIFICATIONS n Industrial,— � ❑ Open Bottom . -_ D Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy m Type of Casing_ Specifications i i"I Public Cl Other n' Delta Depth of Grout Seal Type of Grout I I Irrigation — Approx. Depth I I Eastern 9urface Seal Installed by Repair Work DoneType of Pump Tr H.P. State Work -Done Well Destruction ❑ Well Diameter Sealing Material &Depth r� Depth Filler Material & Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is Cavailable within 200 feet.) Installation will serve: Residence _ Commercial Other Number of living units: Number of bedrooms Character of hsoil to a depth of 3 feet: Water table depth SEPTIC TANK; ❑ Type/Mfg Capacity W No., Compartments PKG. TREATMENT PLT. ❑ Method of Disposal iii Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property, Line - - -- SEEPAGE PITS I I Depth Size _ Number SUMPS�f LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certifypthat I have prepared this application and that the work will be done in accordance with San Joaquin countyordinances, state laws, and rules and regulations of the San Joaquin County Home owner or; licensed agent's signature certifies the following: "1 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 Cal ifornia." The applicant must call for all required inspections. Complete drawing on reverse side. igned X l�, Title: P!" Date: -7/,),-7 / Z I FO DEPVE. ONLY 2 Application Accepted by �2�_ Vim- C s c Date �' [7`� � 1-- Area Pit or Grout Inspection by Date Final Inspection by Date- M III 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 wjNFO '` AMOUNT DUE AMOUNT REMITTED " CK RECEIVED BY DATE PERMIT' NO. . EH 13-24 (kV. riNsin��'� 1 EH 112e li.r