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f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCSTON, 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 7:662 and the Rules and Regulations of San Joaquin County Public Health Services. I Job Address © City Lot Size/Acreage Owner's Name &AaAddress Phone o Xllf ilk Contractor ss �7"s .License No/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPI ACEMENIKM DESTRUCTION ❑ Out of Service well D PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINT: I FOUNDATION AGRICULTURE WELL OTHER WELL PtTS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fel Industrial © Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 91 C7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications W V' r I'1 Public i-1 Other F) Delta Depth of Grout Seal Type of Grout k I I lr,;uation __ Approx. Depth I I Eastern Surface Seat Installed by Repair Work Done Q Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material 3 Depth 0 Depth Filler Material Depth f ,n TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I DESTRUCTION I i. fNo septic system permitted if public sewer is �+ ' available within 200 feet.) Installation will serve: Residence Commercial— Other t + Number of living units: Number of bedrooms r Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r _Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines y Total length/size FILTER BED 0 Distance to nearest: Well dation 4 . Property Line 44. i If SEEPAGE PI 1 1 Depth Size Number MPS C� Distance to nearest: Well o ndation q Property Line _ DISPOSAL PONDS ❑ f/ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate 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 workmen'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 s Cal 71 uired s cons. Com ple awing on reverse side. Signed Title: /'.%rte/) 4 Date: �s FORCQEPARTMENT USE ONLY Application Accepted by _ 1rK r •–� # _ Date Q`T 1 z Area fIL Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services _a{� Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn,- CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED (CASH RECEIVED BY 19-1 DATE PgERMII'^N�O. EH t1-ys[REV.1iwSl 0 Z� [ � C.71