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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES q ENVIRONMENTAL HEALTH DIVISION _ f,Lq 445 N SAN JOAQUIN, PHONE (209)468-3420 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. 7 � Job Address I rq �3CityEo__C� Lot Size/Acreage / Qy Owner's Name /1 1 Address CC�� Q�Ic�� hone/ O Contractor Addres (iY-� ' ce-4 License N131 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (1 DESTRUCTION ❑ Out of Service Well CI _ PUMP INSTALLATION ❑ SYSTEM REPAIR O 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C.l Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public 1:1 Other f1 Delta Depth of Grout Seal Type of Grout I I Irrigation _,Approx. Dept I I Eastern urface Seal Installed by Repair Work Done 6a' Type of Pump HNJ .P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial_ Other J Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line PAYMEAffIf SEEPAGE PITS 11 Depth Size NumberCEIVE[) SUMPS LI Distance to nearest: Well Foundation Property Line Y DISPOSAL PONDS ❑ -BAR 2 9 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin coun%Ab4d1QA0WINa(t bMTVnd rules and regulations of the San Joaquin County PUBLIC HEALTH SERVICES Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for w6NIbIROJ 'kTM1i1�1�1 1()N employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signal. 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 mus II 1 r all required 'nspections. Complete drawing on-reverse side. �q Signed X ' Date: FOR DEPARTMENT USE ONLY Application Accepted by _��-N�-±�` t Data J� Area L, r Pit or"Grout Inspection by l/ Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services „ r DINT2 Environmental Health Permit/Services1 ,(v 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT-NO. � 1 13411REV.1rx51 7R 11"26 _/ '�