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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 14JO ai k &u d W 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 Services. Job Address ZZZ7 W/71i97j4C_7 _-a• .. _ City Lot Size/Acreage ✓ Owner's Name �� Address 7 Phone Contractor% Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE L-1 Industrial F� Domestic/ Private I'l Public I I Irritation Repair Work Done U Well Destruction ❑ TYPF nF WF1 i ❑ Open Bottom • Gravel Pack El Other —, Approx. Depth Type of Pump Well Diameter Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Manteca Dia. of Well Excavation ❑ Tracy Type of Casing - 171 Delta Depth of Grout Seal I I Eastern Surface Seal Installed by H. P. State Work Done _ Sealing Material & Depth Filler Material & Depth f TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTIO Installation will serve: Residence — Commercial — Number of living units: Number of bedrooms _ Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg PKG. TREATMENT PLT. ❑ Distance to nearest: LEACHING LINE C1 No. & Len tines FILTER BED 1-1Dista a io nearest Other pacity Dia. of Well Casing Specifications Type of Grout No septic system permitted if public sewer is available within 200 feet.) Water table depth _ No. Compartments Method of Disposal Welt7�Qt�itRj�y�yiftr'titt SEEPAGE PIT I I Depth Size w r f'] 01 SUMPS Ll Distance to nearest: Welt �] J oL.r j� MnL_-1 eiaM tyt t 6:S1Dn DISPOSAL PONDS Cl 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 subcontracting 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 California." The aplica must call for at required inspections. Complete drawing on reverse side. Signed X Title:`u�ad Date: '1 ^-4:1 7/L F R FITMENT USE ONLY Application Accepted byL. r� Date ` 1-- Area _ 1 Pit or Grout Inspection by Additional Comments: Data Final Inspection by 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 EH 13.24 iREV. i i x 5 EH 14.26 Date FEE INFO AMOUNT DUE AMOU T REMITTED ASH _ RECEIVED BY DATE PERMIT NO. 7�7 6