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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application in 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 �Q' Z6 !� `'�y T 7 City�Y=*10 Lot Size/Acreage /^� Owner's Name S � S Address �!"�/�'�� Phone �+`� -at 3 Contractor // 2J S S Address _ License No3773�I Phone33 Y-y,Z�S TYPE OF WELL/PUMP: NEW WELL �e WELL REPLACEMENT F) DESTRUCTION f7 Out of Service Well ❑ PUMP INSTALLATIONi�7G SYSTEM REPAIR ❑ OTHER E-) Monitoring Well p DISTANCE TO NEAREST: SEPTIC TANK ! Lo SEWER LINES —_ DISPOSAL FLD./S:!52 PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _ i.L�0omestic/Private f6eGravel Pack ❑ Tracy Type of Casing_. _- Specifications I'I Public 11 Other 1I Delta Depth of Grout Type of Grout 5-c-A_A-4-4 M I Irrigation 321t� Approx. Depth I I Eastern Suri a Seal Installe Repair Work Done Ll Type of Pump S H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth l Depth Filler Material Z Depth V T\ 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 feet: --------- Water table depth_ SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal _ Distance to nearest: Well Foundation Property Line LEACHING LINE D No. b 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 workmen'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 all 1 Ir allrequiredinspections. Complete drawing on reverse side. `` q Signed X_�! y ✓/it.�- Title: SCCA^_ - -- Date: T L 7- C Z FOR DEPARTMENT USE ONLY Application Accepted by Date I�/ -GA) Z Area o s Pit orout Inspection by to Final Inspection by 1� t Dats- ' r Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 173-01711 INFE AMOUNT DUE AMO T REMITTED CK 11 CASH RECEIVED BY DATE PERMIT NO EH 1JNlaEv t1hsi �i)� [ l2 FH 14 M /�J