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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 vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address icy Lot Size/Acreage 1 7_ �30 1,4 r Owner's Nam ress Phone Contra c r Address�f � License No Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 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 1MELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ` Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F] Domestic/Private ❑ Gravel Pack n Tracy Type of Casing_ Specifications I'l Public C] Other ❑ Delta Depth of Grout Seal Type of Grout 4 Ii Irrigation Approx. Depth I I Eastern Surface Seal Installed by i Repair Work Done ❑ Type of Pump H.P. State Work Done_ Sealing Material Depth Weif Destruction ❑ Well Diameter & Depth ler Material ii Depth ` TYPE OF SEPTIC WORK: NEW INSTAL TION I I REPAI ADDITlO DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet-1 Installation will serve: Rosi encs_ Commer ial OtherZ�s Number of living units: Number of be r oma f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Type/Mfg "Ie Capacity No. Compartments �2 PKG. TREATMENT PL ❑ r Method of Dispral Distance to nearest: Well ;�, F9undation /4Q Property Line LEACHING LINE No. & Length of lines "' Total length/size � r I FILTER BED l❑ Distance to nearest: Well_�/7l Foundation�� _ Property line SEEPAGE PITSDepth Size Number SUMPS Ll Distance to nearest: Well Foundation j!!�Q 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 Cslifornis." _ The applican ust call for equ d inspections. Complete drawing on reverse side Signed X Title: - ------- ---_- - date i F ART�MFNT�USELY17 27 I^ Application Accepted by �� Y� Date !'Area Pit or Grout Inspection by Date Final Inspection by ,Date-7—22 l 2 Additional Comments: * Y Applicant - Return all copies to: San Joaquin County Public Health Services I? Environmental Health Permit/Services + 445 N San Joaquin, P 0 Box 2009,._Stkn, CA 95201 h FEE AMOUNT DUE AMOUNT REMITTED GAS RECEIVED By D TE` PERMIT'NO, INFO n �J . EH 13.24(REV.fiK51 ""�\ i EH 74-26 "`cccJJJ • E