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" � f r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 1 O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San lquip County for a permit to construct and/or install the work herein described. This application is Stade 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Service+. City w/ Lot Size/Acreage Job Address M l Owner's Name �,lR �T_ Address SA J10 e �S 20 7 Phone 7- ��-- - - S� �� Phone251�—M 17 Contractor�d Address License No. TYPE OF WELL/PUMP. NEWJWELL ❑ WELL REPLACEMENT n W DESTRUCTION ❑ Out of Service e ❑ PUMP INSTALLATION � SYSTEM REPAIR ❑ OTHER ❑ Monitoring Nellll [73 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DESPOSAL FLD. PROP. LINE Q FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS � ` 1 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 Pack C7 Tracy Type of Casing_ Specifications I'1 Public x� I.1 Other _ F1 Delta el Depth of Grout Seal Type of Grout I I Iffigation _.Approx. Depth I i Eastern Surfaoe1�a Installed by Repair Work Done L] Type of Pump g[�f�i H.P. l I-V( State Work Done Sealing Material & Depth C(/1 ` ,Well Destruction ❑ Well Diameter T- `` Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION { I DESTRUCTION l I (No septic system permitted if public sewer is I 1 available within 200 feetJ Ian Installation will serve: Residence Commercial— Other 3 ik Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:' Water table depth I SEPTIC TANK O Type/MfgCapacity=--- - --No. Compartments u PKG. TREATMENT PLT. ❑ t Method of Disposal (1 Distance to nearest: Well Foundation Property Line Q _ w LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line t� DISPOSAL PONDS ❑ 3 I hereby certify that I have prepared this application and that the work will be done in accofdance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County Home owner or ficen'sed 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 cenifies 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 California." ,..I i . The applican t cap for all required ins coons. omplete drawing on r Title: ate: �9 Signed X D ` FOR DEPARTMENT USE ONLY Application Accepted by r Date Area Pit or Grout inspection by Date Final Inspection by Date / Z Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, GA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVE181Y DATE PERMIT'NO. INFO . EH 13-24(REV.110%61 �K/ �t�J `t�e 7Q� ! ��^ 1 Z [Z.'..] 'EH 14•26 1V 3 i