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_ w SAN JOAQUIN COUN= PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 ( P 0 BOX 2009, STOCKTON, CA 95201 }��--`w" 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 Services. J Job Address � 16 10f ✓ [' City v�ot Size/Acreage Owner's Name Address Phone Contractor Address�P /7 fes/ .� ��cL?License No. t� Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FI DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 F) industrial ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack D Tracy Type of Casing_ Specifications I'] Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation — Approx. De th I 1 Eastern Surface Seal Installed by Repair Work Done � Type of Pump.De H.P. _ 2 State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION I I DESTRUCTION ! 11No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence..r Commercial —,—,. Other Number of living units: Number of bedrooms Character of soil to s depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines *Total length/size FILTER BED C] Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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 Sen 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 taws of California." Contractor's hiring or subcontracting 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 ompansa- tion laws of California." The applica st call or all required ins ctians. mplete drawing on revg9 side. Signed X Title: ._ �P� _ Date: / kRTMrN- _USE ONLY Application Accepted by Date Z Area d Z Pit or Grout Inspection by 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 O Box 2009, Stkn, CA 95201 FEE IINFO AMOUNT DUE AMO T REMITTED CAS CK RECEIVED By DATE PERMIT NO. n . EH 13.241NEY,rirs / � 0 EH 14.26 U /