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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �g, 445 N SAN JOAQUIN, PHONE (209)468-3420 `�'�r P O BOX 2009, STOCKTON, CA 95201 1 4 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 trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. City Lot Size/Acreage lob Address Owner's Name ^� 's'1°Q,� Address Phone ��t,, Contractor ~nr''r� Address License NoR0903 I Phone TYPE OF WELL/PUMP: Nk:VV WELL M WELL REPLACEMENT I1 DESTRUCTION Out of service Well ❑ PUMP INSTALLAT SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C� DISTANCE TO NEAREST: SEP ANK SEWER LINES DISPOSAL FLD. PROP. LINE OUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p, n Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 11 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications V1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Sedl Installed by Repair Work Done L] Type of Pump H.P. State Work Done Wait Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 leet.i Installation will serve: Residence_.._ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal o Distance to nearest: Well Foundation Property Line th/size LEACHING LINE ❑ No. & Length of lines Total len fd FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number l SUMPS CI 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 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 c II for uir inspections. Complete drawing on eve side. �^ Signed X Title: r Date: FOR DEPARTMENT USE ONLY Application Accepted b Date Area RP P Y Pit or Grout Inspection by Date Final Inspection b `a2=0 to ail , Additional Comments: Applicant - Return all copies to: San Joaquin`County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CA9 RECEIVED BY DATE PERMIT'ND. INfO . EH 14.21IREV.vHSI ��Iz EK 14-26 ��lll/// '