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F SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, 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 1862 and the Rules and Regulations of San Joaquin County Public Health S vices. Job Address CityL JAI OC—AlLot Size/Acreage Owner's Name I A67Address Phone Contractor Address iJ r"iC— License N Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well CI PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well DISTANCE TO NEAR TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION ULTURE WELL OTHER WELL S INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTR NS 3 C7 Industrial (03 Open Bottom ❑ Manteca Di xcavation Dia. of Well Casing Ca Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing_ Spec ons I'I Public 1 1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation prox, Depth I I Eastern Surface Seal Installed by Repair Work Do Type of Pump H.P. State Work Done _ Well De ction ❑ Well Diameter Sealing Material & Depth i Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet,) Installation will serve: Residence— CommerciaE Other _t Number of living units: Number of bedrooms /s.11 . Character of soil to a depth of 3 feet: 41�1 h Water table depth SEPTIC TANK ❑ Type/Mfg ��2 f Capacity d_iJ No. Compartments PKG, TREATMENT PLT. ❑ Method off �D.isp�osal Distance to nearest: Well Foundation Property Line �(� �{/""y LEACHING LINE D No. & Length of lines Total fengthlsize FILTER BED ❑ Distance to nearest: We Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation��"��,� Property Line DISPOSAL PONDS 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 F rules and regulations of the San Joaquin County Home owner or licensed agent's signature cenifies 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 taws of California." Contractor's hiring or sub-contracting signature certifies�following: th he performance of the work forwhich this permit is issued, I shall employ persons subject to workman's compensa- tion lawThe ap uir in ctions. Complete drawing on r r side. g Signed Title: i/".n Date: FOR DEPARTMENT USE ONLY Application Accepted by Date ` Area W1 Pit or Grout Inspection by Date Final Inspection by_XaData Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services e 445 N San Joaquin, 0 Box 2009, Stkn, CA 95201 I INFO FEE / EH 14.25 III AMOUNT DUE AMOUNT REMITTED I JCK#Jr CEIVED BY yA(TE 171:;f EAMMIEH 13-21(REV.t ix si / C/ Vv� VV ti