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SAN (7UIN COUNTY PUBLIC HEALTH SNCES ENVIRONMENTAL HEALTH HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 FILE C PERMIT EgPIRES 1 YEAR FROM DATE ISSUM (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 T9 AL A421� _ City Z Lot Size/Acreage w �` Address3�` ' Phone Owner's Nameaii� �-�- e, �—��► 3 Phone �l7 Contractor Q1�i Address License No TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service well ❑ PUMP INSTALLATION SYSTEM.REPAIR ❑ OTHER ❑ Monitoring well L3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FL0. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing n Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation - 'a- ofWellSpecifications Type of Casin f�}omesticlPrivate ❑ Gravel Pack E7 Tracy 9— Type of Grout 1'1 Public Cl Other fl Delta Depth of Grout Seal I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done Sealing Material & Depth rf4Jll�a� Well Destruction ❑ Well Diameter � Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADDITION I I DESTRUCTION I I (Neils Iptic system m permitted if public sewer is Installation will serve: Residence T Commercial— Other Number of living units: Number of bedrooms Water table depth Character of soil to s depth of 3 feet: SEPTIC TANK. ❑ Type/Mfg Cspacity No. Compartments PKG. TREATMENT PLT. ❑ - Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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!tiring 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 mu all for all required ins tions. omplete drawing on r rse sirZ Signed Title: Z Date: (� R DEF4RTMIENT USE ONLY Application Accepted by o ' fl - Date..:&132— Area Pit or Grout Inspection by Date Final Inspection by 7Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public health Services t ` Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEAMOUNT OlIE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. i FO IN ! f]� . EN U60,-211REV.i/x51 � [ EFF 14-26 _ !li