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V SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION EN" 445 N SAN JOAQUIN, PHONE (209)468-3420 J U N 15 P O BOX 2009, STOCKTON, CA 95201 ENVIRONMENTAL HEALTH I PERMIT EMPIRES f YEAR FROM DATE ISSUED PERM11T65HV1U,5 (Complete in Triplicate) i Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is rade in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 76/6 City Lot Size/Acreage I (( OWL's Nam Address Phone i Q Co traeto� ��/ es Z/ / cense No.__hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL7EPLACEMENT [I DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION (� SYSTEM REPAIR ❑ OTHER El Monitoring Well DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE Of WELL PROBLEM AREA- CONSTRUCTION SPECIFICATIONS F) Industrial ' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing omestic/Privates_•—} ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications i I'I Public C] Other n Delta Depth of Grout Seal r Type of Grout I I Irrigalion • —.Approx. Depth I J Eastern Surface-Seul Installed by Repair Work Done 13 Type of Pump r H: --- -__ State Work Done . Wel•Aestruction O ` Well Diamet �.�^Seeling Material Depth .._Depth_ /it Filler Material b Depth TYPE'OF SEPTIC WORK: NEW INSTALLATION I I REPAIRJADDtTION I I DESTRUCTION I I INo septic system permitted if public sewer is j ; available within 200 feet.) Installation will serve: ,Residence� Commercial Other Number of living units: Number of bedrooms ! Character of soil to a depth of 3 feet: `� } Water table depth C SEPTIC TANK ❑ Type/Mfgt wA. Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest; Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines ' Total length/size FILTER BED ❑ Distance to nearest: Well t Foundation Property Line F 1 SEEPAGE PITS 11 Depth Size Number r SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt be done in accordance with Sari Joaquin county ordinances,- state laws, and- r 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 i employ any person in such manner as to become subject to workman's compensation laws of California." ontrictor'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 a toy persons subject to workman's compensa- tion laws of California." f The applicant si callfor 11 r uire inspections. Complete drawing on revOle side. / Signed Titl ' Data: FOR DEPARTMENT USE ONLY Application Accepted by : Date (a 1-7 — Z- Area r � Z Pit or Grout Inspection by Date• Final Inspection by Date Additional Comments: I i Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 i 5FEE AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMIT No. INFO OQ . EH 13.24(REV.IIS 51 lS r EH 14.25