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1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION a 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 , PERMIT EXPIRES I 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. �r I Job Address C City S Lot Size/Acreage 4 Owner's Name` t � Address 5.�� 'l� Phone 31,- M Contractor ddress t License No Phone /may TYPE OF WELL/PUMP. NEW WELL ❑ WELL RE CEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0-5- -,, OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.L PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL ' PITS/SUMPS INTENDED USE TYPE OF WELL -PROBLEM AREA rCONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom _ ❑ Manteca Dia. of Well Excavation - " Dia. of Well Casing t (1'Domestic/Private ❑ Graffi,Pack ❑ Tracy Type of Casing_ Specifications CI Public i-1 Other - fl Delta Depth of Grout Seal Type of Grout ,_._.I 1 irriS7ation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work'Done r n Well Destruction p Well Diameter Sealing Material & Depth v\ Depth Filler Material b Depth 0 '. TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION l 1 (No septic system permitted if public sewer is " available within 200 feet.) Installation will serve: Re --sidence A— Commercial Other LNumber of living-units: ,,� _L_- f Number-of bedrooms i Characteu of soil to.a depth of 3 feet: , Water table depth SEPTIC TANK ❑ Type/Mfg -elq CapacityY No. Compartments tl PKG. TREATMENT PLT. ❑ Method of Disposal ` Distance to nearest: 'Well— Foundation Property Line k .. LEACHING UNE ig�p No. & Length of lines - Total length/size FILTER BED ❑ Distance to nearest: Well, ' Foundation - r Property Line ; SEEPAGE PITS J>T Depth Size 3 -Number I SUMPS Lt Distance•to nearest: Well Foundation Property Line t 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, state laws, and rules and regulations of the San Joaquin County _t Is I 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 work man's'compensation taws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work folf which this permit is issued,.l shall employ persons subject to workman's.compensa--- tion laws of California," �" The applicant m t call for all r ire "_spections omplete"drawing=on- erie- ids., Signed Title: FOR DEPARTMENT USE ONLY - Application Accepted by J' y Date r Area Pit or Grout Inspection by Date Final Inspection by Date f , Additional Comments: 1,00k 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 FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT*NO. INFO CASH �+ �v( f f I . EH i3-74tREV.i1nsf 3X,2 ! 1 �f `5l I-> EH t�•Ia 7