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i J SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL IREALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2019, 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 1662 and the Rules and Regulations of San Joaquin County Public HealthSe�s. Job Address 6 City e52 h Lot Size/Acreage L /K Owner's Name �-��! eY✓P� +��Address Phone Contractor ' Address G Yo License Noy. 12Phone TYPE OF WELL/PUMP: NEW WELL fl WELL REPLACEMENT F DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR l' OTHER ❑ Monitoring Well [7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Well Casing KDomestic/Private ❑ Gravel Pack ❑ Tracy, Type of Casing_ Specifications I'] Public .4 El Other fl Delta Depth of Grout Seal Type of GroutNJ I I Irrigation _ Approx. Depth 13 Eastern Surf a-Seal-Installed by - c Repair Work Done 11 Type of Pump H.P. 4_ State Work Done G Well Destruction ❑ Weil Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIR/ADDITION ( I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms f v Y 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 Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total lengthtsize FILTER BED ❑ Distance to nearest: Well 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 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 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 applicant call r all required ins ions. Complete drawing on rev s side. Signed W—KTitle: Date: D�EPAR—T-MENT USE ONLY Q Application Accepted by wCy� �FOFI �saaAr�� Date 17=�` l� Area C3 Pit or Grout Inspection by Oate Final Inspection by'T_eI150_22A=dfa-t'/___ - Date L Z Additional Comments: 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 FEE INFO MOUNT DUE AMOUNT REMITTED CK EIVED BY DATE PERM17'N0. • EH t1241REV.�iXSVIP g-9 a J 9 EH 14.26 I