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SAN JOIN COUNTY PUBLIC HEALTH SEiJCES �'J ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON$ CA 95201 P . ERMIT EXPIRES 1 YEAR FROM DATE ISSUED ri (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 Services. Job Address Owner's Name J � .�,� Citv's Wt Size/Acreage �o rrGz.r •/ 5 66 Phone 1-4� 3 /1 Address Contractor R69WA 0. Address License No.(OZZ:93 a Phone) 'fta'i TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well ❑ 12 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER XMonitoring AIS DISTANCE TO NEAREST: SEPTIC TANK . A/A - SEWER LINES 1 SD ��r�LL DISPOSAL FLO.� PROP. LINE = 4 FOUNDATION — AGRICULTURE WELL __A__ OTHER WELL L PITS/SUMPS T INTENDED USE ❑ Industrial XDomestic/Private I'I Public TYPE OF WE PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Gravel Pack*1 © Tracy Type of Casing_ Specifications.. .010 OtherDelta Depth of Grout Seal ✓t + s Type of Grout 6AT CF I I Irrigation Approx. Depth 11 Eastern Surface Said Installed by Repair Work Done L3 Type of Pump H. P. State Work Done _ Well Destruction ❑ Well Diameter I�I Sealing Material i Depth Depth Filler Material i Depth fJ TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is O available within 200 feet.) �1 Installation will serve: Residence _ ,� Commercial Other Number of living units: Number of bedrooms Character of soli to a depth of 3 feet: 1i Water table depth SEPTIC TANK. ❑ Type/Mfg �� k Capacity No. Compartments PKG. TREATMENT PLT. ❑ I M of Disposal / Distance to `nearest: Weil Foundation Pro R LEACHING LINE f41a ❑ No. & Length of lines Total length i FILTER BED ❑ Distance to'nearest: Well Foundation Pro TinY A SAN 10AQUINCOUNTY SEEPAGE PITS NIA 11 Depth `I Size NumQU LIC HEALTH 5EXVICES IA" SUMPS � LI Distance to�'nearest: Well iFoundation ENVa DISPOSAL PONDS ❑ i 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 o1 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 California." The applicant ust call for 1 wired in Ipections. Complete drawing on -reverse side. Signed Tule: �2yt/O� S" +.S Date: s �/ ,f i FOR DEPARTMENT USE ONLY Application Accepted by 11 Date S �" Area Pit or Grout inspection by ` T ate i� Final inspection byd-e Date ! — Additional Comments.- Applicant omments: Applicant - Return all copies to: San Joaquin.County Public Health Services 4} / Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 . EH 1344 (REV. 1/ K 5) EH 14.76 FEE INFO AMOUNT OVE AMOVNT REMITTED CX CASH RECEIVED BY DATE PERMIT'NO.