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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l I ��'` ✓ �p� L (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 Services. '� Job Address —1 a City S 1_-_X� Lot Size/Acreage Owner's Name � c dAddress Phone Contractor ��/_C Address �� G-[��t'G�t— License No.392�,9_0 Phon TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR eK OTHER ❑ Monitoring Well L7 1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation __ Dia. of Well Casing Domestic/Private ❑ Gravel Pack n Tracy Type of Casing_ Specifications I'I Public 0 Other F, Delta Depth of Grout Seal Type of Grout I I Irrigation ____Approx. Depth I I Eastern Surface Seal Installed by \\ Repair Work Done Zf Type of Pump S H.P. State Work Dan a Weil Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I l DESTRUCTION I I INo septic system permitted it public sewer is 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well` foundation Property Line ' i LEACHING LINE 0 No. & Length of lines Total lengthtsize FILTER BED ❑ Distance to nearest: Well Foundation Property Line \ K SEEPAGE PITS } 11 Depth Size Number V SUMPS CI 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 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 workman's compensation taws 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 m for all required ins tions. Complete drawing on raver s+ e. .Z Signed X Title: Date: - -. F .DEPARTMENT USE ONLY - Application Accepted by Date Z' Area 2 .. ; Pit or Grout Inspaction by Date Final Inspection by /' Date !� Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P ox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BYTE PERMIT'NO. i INFO /// 2 91�tL/W EH 13-2t tREV.+/KslQEH l�•26 —J