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SAN JOAQUIN COUNTY PUBLIC HEALTH SEhov'ICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 F" 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 is co®pllance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County NblicAlealth Services ddress L - Job Address ` City Lot SSze/Acreage LL Owner's Name Address I DOaww!�* LL_,one Aicense No. V � Phone Contractor TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ( OTHER Q Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK :SEWEA LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS c INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -F n Industrial O Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing Domestic/Private 0 Gravel Pack* ❑ Tracy- Type-of Casing Specifications VI Public 1-1 Other I-1 Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern_ Surface Seal Installed by Repair Work Done U Type of PumpH-P• — State Work Done Well Destruction ❑ Well Diameter I j Scaling Material j'-Depth I Depth _ 1An r Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I i (No septic system permitted it public sewer is k available within 200 feet.) I FInstallation will serve: Residence Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth E SEPTIC TANK ❑ Type/Mfg Capacity No. �"iiSf3P , FPKG. TREATMENT PLT.❑ Met� {1� '. r Distance to nearest: " Well Foundation Property Lrne �'0 lE II 1-91-1292 LEACHING LINE ❑ No. & Length of lines Total Iengthl%)M.,+ :^ •1 FILTER RED ❑ Distance to nearest: Well Foundation ProtikUr4� _" �,y/j5 �NVIRONMEN161 HEA1 TU D11,JJQiQN F- SEEPAGE PITS 11 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Ll FI hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, 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 workmen's compensation laws of California.-Contractor's hiring or sub-contracting signature certifies the fopo g:.,I certify that in the performance of the work for which this permit is issued,I shalt employ persons subject to workman's compensa- tion laws of 1 nla." Fk The applic t t tail for all req 'red inspect' S. Complete drawing on ve side. Signed Tille: MCDate: .FOR DEPARTME USE ONLY F Application Accepted by Data Area 1 —� Pit or Grout inspection try Date Final Inspection by Date Additional Comments. d Applicant - Return 411 copies to: San Joaquin County Public Health Services I Environmental Health Permit/Services 445 N San Joaquin, Box 2009, Stkn, CA 9520.1 2{ IFEE NFO AMOUNT DUE AMOUNT REMITTED CK H CElVEa By DATE PEFIMIT'NO. k F:,24IIIEV-r/K5)b2e 1_ 1 I