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RpICES SAN AQUIN COUNTY. PUBLIC HEALTHY ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)488-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE JSSZTED (Complete in Triplicate) i 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 e an Joaquin County Public Health Services. Tan if Job Address � City Lot Size/Acreage � d Owner's Name t/t'I7- Address lv - Phone Contractor u1?41 <70ALit t'.a Address .2,1 &f 76 % License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (1 DESTRUCTION ❑ Out of Service Well ❑ i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L3 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing 11 Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications I'1 Public El other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done 0 Type of Pump ~ H.P. State Work Done_ Well Destruction ❑ Well Diameter. Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION (Nor septic system permitted if public sewer is available within 200 teat.) j Installation will serve: Residence Commercial_ Other i Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacit y No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. &.Length of lines Total length/size FILTER BED 0 Distance to.nearest: Well . Foundation Property Line SEEPAGE PITS It Depth Size Number SUMPS CI Distance to nearest: Well Foundation . Property Line DISPOSAL PONDS ❑ 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an 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 In employ any person in such manner as to become subject to workman's compensation laws of California," Contractor's hiring or sub-contracting signature l 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 mu tett for all req ed inspections. Complete drawing on reverse side. w Signed Title: f Date: _ FOR DEPARTMENT USE ONLY v l Application Accepted by�~ Dare; 6 � - Area G Pit Grout Inspection by a Final Inspection � Date�_'�'L Additional ional Comments: .by I'f,� Applicant - Return all copies to: San 'Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin,..) O Box 2009, Stkn, CA 95201 N FEE jCE4TD1U1E AMOUNT REMITTEDifINFO 7 CASH RECEIVED BY DATE PERMIT•N0. En 14.26 .rrn i