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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 1 P O BOX 2009, STOCKTON, CA 95201 -PERMIT FIRES 1 YEAR FROM DATE ISSUED ..I (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 8ervice+. Job Address City 'Lot Size/Acreage Phone ' Owner's flamed4 4642-i?�r Address Contractorddmis t� 7 laLet License No �Phone TYPE OF WELL/PUMP. NE WELL ❑ WELL REPLACEMENT E7 DESTRUCTION ;'Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR El 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 E7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F1 Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing Specifications I'1 Public 1-1 Other M Delta Depth of Grout Seal Type of Grout I I Irrioation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. _ A State Work Done �� Well Destruction � Well Diameter r Sealing Material & Depth /fir , jfa Depth �j filler Material & Depth 7y i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet,) I Installation will serve: Residence____ Commercial____ Other y Number of living units: Number of bedrooms ]!I Character of soil to a depth of 3 feel: f � Water table depth SEPTIC TANK ❑ Type/Mfg ( s' '=f Capacity No. Compartments _ PKG. TREATMENT PLT. ❑ �* Method of Disposal �[1 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth -Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 std regulations of the San Joaquin County Home gwnor 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: '9 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�itlf California." The applican us t� re ons. Complete drawing on r v fse side. `� Signed X Title: "~ Data: / � OR ZPARTMENT USE 1VLY r! Application Accepted by ._ nnnD/M+'� Date —I- O`3-1Area ., + + Pit or Grout Inspection by Date Final Inspection by Data t y Additional Comments: w i ` 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 AMOUNT Due AMOUNT REMITTED H RECEIVED BY DATE PERMIT"N0. INFO //� ��y�� . EH 1J211REV.litfSi �. fit • �/E�t "'v D I^a�3 /L •��/7( 49 EH 11.2E �1�' iO r/l+