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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 (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. �f `� Job Address �+ 0 T � J city e Lot Size/Acreage Owner's Name L2 thA C_ h"A9dress Phone Contractor feleF Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well 71 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 C-} Industrial ❑ Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing i Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications I'1 Public t.l Other fl Delta Depth of Grout Seal Type of Grout 13 Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P, State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 3 Depth Depth Filler Material Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION 1-t—DESTRUCTION I I (No septic system permitted if public sewer is available within 20O feet.) ^ Installation will serve: Residence Commercial_ Other 0�\ Number of living units: _./. Number of bedrooms 3n / Character of soil to a depth of 3 feet: s/ , .` S'.. Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ry f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 14'Distance to nearest. Well � b Foundation r __� _ _ Property Line A SEEPAGE PITS 11 Depth Size Number ' SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stale 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 �xz l fka' 'M l r )a tions. omplete drawing on reverse side. Signed X Title: Date: 61 - - � F EPA 5E ONLY Application Accepted by Date rea Pit or Grout Inspection by Date Final Inspection Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 IN AMOUNTDUE AMOUNT REMITTED CK RECEIVED BY / DATE PEAMIT'NO, fM 07/ 13-24rREV.iix5) ` / EH 14-Ie F