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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES f 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 ie 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. ' &kl Job Address City Lot Size/Acreage Owner's me ddress CLAM ^ r , �r Phone Q31-o3 I !`fit o( 1 a W Contractor A s e No.4N Phone �� TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT C) I DESTRUCTION ❑ Out of Service Weli ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ._INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial f ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing %I I omestic/P`rivate ❑ Gravel Pack ❑ Tracy Type of Casing._ Specifications I'I Public 'f e / C Other Cl Delta Depth of Grout Seal Type of Grout I i Irrigation 0 _._Approx. Depth l kEastern Surface Seal Installed by Repair Work Dane- 0 /Type of Pump H.P. _ State Work Done Well Destruction ❑ WeII:Di me Sealing Material & Depth ' Filler Material & Depth �Dept I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I {No 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 Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg i Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line t .� LEACHING LINE D No. & Length of lines Total length/size TTS FILTER BED ❑ Distance to nearest: Well Foundation Property Line f ✓ SEEPAGE PITS 11 Depth Size Number r SUMPS Ll Distance to nearest; Well Foundation Property Line h.- DISPOSAL PONDS ❑ I hereby ceriify 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 Couhty i Home owner or licensed agent's signature certifies the following: ';1 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 apps a �ust call I e ired i sPections. Complete drawing on r rse rid Signe Title: "Date: ` Df E-ONLY �_ A. Application Accepted by _ t,n s-+ )D'ate �rS Area s Pit or Grout Inspection by _Dates-� n{Fi.hal Inspection by, Data L3 g Additional — Additional Comments: [SGC E'j Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joageiin,. O Sox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED, �K RECEIVED BY DATE PERMIT'NO. INFO M 4 . H 13.24{ptEV,i/x Sl 5 v-0 E I EH i4•I(S ..