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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-0420 P O 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. .� Job Address / L.'r/ :! z C<Z! '�% City C t Lot Size/Acreage c � 1 Otiner's Name ';7,-,-)-7 )Q-,A � �- Address Phone 1 �r � 7r r Contractor F �Zd� Address `•- �Lr` ! License Pio. r Phone�+y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION Cl Out of Service Well ❑ 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 F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ _ Dia. of Well Casing _ Ca Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing____ Specifications I'1 Public Ll Other fl Delta Depth of Grout Seal Type of Grout_ I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done E 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 IV REPAIR/ADDITION I I DESTRUCTION I (No septic system permitted if public sewer is �J available within 200 feet.) Installation will serve: Residence L_ Commercial _ Other Number of living units: 1 Number of bedrooms __67___ Character of soil to a depth of 3 feet: —Water table d.F,th SEPTIC TANK ❑ Type/Mfg �/ Capacity--^t/C� No. Comparlin*M5 — PKG. TREATMENT PLT. ❑ _ Method of f�Disposal _ Distance to nearest: Well Foundation 42 _ Property Line LEACHING LINE Ll No. & Length of lines - Total length/size FILTER BED Ll Distance to nearest: Well fr Foundations Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well f,!5Foundation Property Line DISPOSAL PONDS O 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 Horne owner or licensed agent's signature certifies the following: "I certify that in the periormance 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 must must,,call for all required inspitctions. Complete drawing on reverse side. �� s Signed X_�� f7(C"_L �r 4 f Title: Lz,e"---) r Da ie: F R DEPARTMENT NT USE ONLY f t Z r 7) Application Accepted by - r - Date �" 1 Arer or Grout Inspection b � ' ��'>-��G ate �' ! Final Inspection by c �T ._ 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. Stkr,, CA 95201 FEECK INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY I DATE PERMIT NO 13-24(REV 1 51 J ` - i