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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - f ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 ( P 0 BOX 2009, STOCKTON, CA 95201 p�, ��J" l� 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 coWliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San y /Joaquin County Public Health Services. y� f/Job Address �� City 51` I Lot Size/Acreage V/Owner's Name 9 "' � Address f 3,27 �d� �� Phone i Contractor Address License No. Phone TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR C7 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 C7 Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing i 10) FI Domestic/Private L1 Gravel Pack L7 Tracy Type of Casing_ Specifications I'] Public 1.1 Other 1 fl Delta Depth of Grout Seal Type of Grout I I Ifrioation _Approx. Depth I ) Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work DoneAlp _ Well Destruction ❑ Well Diameter Sealing Materiel & Depth Depth Filler Material A Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION INo septic system permitted if public sewer is /' � .- available within 200 feet.) Installation will servo: Residence + Commercial_ Other i Number of living unite: Q>Number of bedrooms Character of soil to a depth of 3 feet: 4 Water table depth SEPTIC TANK O Type/Mfg CapacityN_o. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to mearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length-of fines Total length/sire FILTER BED ❑ Distance t6 nearest. Welt Foundation Property'Lin®— SEEPAGE PITS 11 Depth Size Number SUMPS CI Distance t6*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, f shell 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 I of California." The app 01. st f.,.,It r ins pe to s. Complete drawing on reverse side. Y Signed X l Title: -- bats: `3aL�p�, FOR DEPARTMENT USE ONLY Application Accepted by Date_ L Area l Pit or Grout Inspection by Date Final Inspection by ! Date t Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services j 445 N San Joaquin Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE { AMOU T REMITTED CK H CEIVEI] BY ATE PERMIT'NO. EH 1324[REV,iiass EH 1420 f