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tv f4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. 17 Job Address �� • ' '� ^! City Z—A::�- - Lot Size/Acreage Owner's Name Address Phone Contractor A, Address icense N Phone ,2— +� TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT R DESTRUCTION n Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Pr 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications \�1 1'I Public El Other n Delta Depth of Grout Seal Type of Grout v I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done * Type of Pump �� H.P. ^ ;L State Work Don92 Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.l Installation wiii 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 • ❑ Type/Mfg Capacity No. Compartments , PKG. TREATMENT PLT. ❑ Method of Disposal : . Distance to nearest: Well Foundation Property Line F LEACHING LINE D No. & Length of lines Totai length/size FILTER BED F) Distance to nearest: Wall 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 wilt 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 C The appl' nt must 1 for all required i rtions. Complete drawing on revers sid Signed Title: Date: v FOR DEPARTMENT USE ONLY c Application Accepted by AcAA.. � - jl hJN9sr1&J % Date rea 2/1 2 _ Pit or Grout Inspection by Data Final Inspection b Date 4� Additional Comments: Applicant •- Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, O Box 2009, Stkn, CA 95201 INFO FEE AMOUNT DUE AMOUNT REMITTED CK CEIVED BY p TE PERMIT�NO, j . EK 13.2 IREV. i n si !] 0(7 O� dJ/J q/ I