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SAN Jr)AQUIN COUNTY PUBLIC HEALTH 'WICES NVT110NMENTAL HEALTH DIVISI 445—n SAN JOAQUIN, PHONE (209)46$`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 i k Ere-,CQ?ibY. This application is made in coa>pliaAce with San Joaquin County Ordinance No. 549 and 1862 and t }}}}}}�� es a.nd egne of San YJoaquin County/Public Health Services. • /� C/,, �;, J ob Address 1 ( � • �J1<<r�-�'TT_City /��i� Lot Size/Acreage 0 Owner's Name - w y�Y —�/� c-+�gddress l 40I �Ze��rr Phone it 73 /.S ontractor AI'4 �i SAddress License No. Phone TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well UT PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well O 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_1 Industrial O Open Bottom O Manteca Dia_ of Well Excavation Dia. of Well Casing I Domestic/Private 0 Gravel Pack M Tracy Type of Casing__ Specifications e--- 'I Public f7 Other' fl Delta Depth of Grout Seal Type of Grout I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by UJ Repair Work Done U Type of Pump H.P. State Work Done _ J Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence _ Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feel: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Properly Line LEACHING LINE D No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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, 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." Contractors 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." �•y/T�he applicant must call for all required inspections. Complete drawing on reverse side. C� gned X �srz;� �/ ��+.� Title: Date: _ 3 73—19 DEPARTMENT USE ONLY Application Accepted by C�- `� Date _ Z ea Pit or Grout Inspection by Date Final Inspection b Dete Z Additional Comments: r.A UM A Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUEAMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT NO.