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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES _S ENVIRONMRNTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 + P O BOX 2009, STOCKTON, CA 95201 A/v Vwru� 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �7 (Complete in Triplicate) ��Zock, �'1��• 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 trith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �` y X Job Address _�. --+ v� rWr ,- City hot Size/Acreage k6x 1 ZO Owner's Name Address 2 w• wr't l 1 f r Phone �i o— r k Contractor ,v � Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 p Manteca Dia, of Well Excavation _Dia. of Well Casing E) Domestic/Private 0 Gravel Pack Trac T " — Y yPe of Casing=- Specifications I'} Public is Other Fl Delta Depth of Grout Seal Type of Grout U f I I Irrigation _,.Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done U Type of Pump I H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth n Depth . Filler Material & Depth' TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION,I IDESTRUCTION X IN septic system permitted it public sewer is vai a within 200 feet.) ^{ installation will serve: Residence_._.,. Commercial T Other f Number of Ir nits: Number of bedrooms 'I Character of soil to a dap feet: Water table depth 4 SEPTIC TANK ❑ Type/Mfg + Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Fou Tn Property Line ' t LEACHING LINE ❑ No. & Lengt lines Total lengt FILTER BED [.1 Oista to nearest: Well�_ Foundation Property Line SEEPAGE PZNDS I Depth r Size'— Number SUMPS LI Distance to nearest: Well. Foundation Property Line DISPOSAL ❑ 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: 1 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 ust call for all re uir ins tions. Complete drawing on reverse side, i ✓Signed X Title: , AA. _. _ Date: �� Z FO DEPARTMENT USE ONLY Application Accepted by Date Area C Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, x 2009, Stkn,, CA 95201 FEE INFO AMOUNT DUE �AMOUNT REMITTED C K RECEIVED BY DATE([ PERMIT'NO. . EH12.2 IREV,rix i 4� EH 14.26 ,J r/l i