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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 r I P 0 BOX 2009, STOCKTON, CA 95201 PERMIT MIRES 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 compliances 3with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. , `f ! E Job Address City Lot Size/Acreage Il n 's Name ddress Phone h `? es L cense No. Phone`l - _ TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATIO - SYSTEM REPAIR ❑ OTHER 0 Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS `N C] I dust na! p Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing stic/Private Cl Gravel P1.ack C7 Tracy Type of Casing_ Specifications.. - !!!///I'I Public """"""`""l l"Ot ei�"""s �1 Delta-` DBpth 6f-Gtorir-Seal Type o}-Grout--��_„_� I I Irrigation _.Approx. Dept I I stern Surface Seai installed by / Repair Work Done L] T l�, ! # Type of Pump H.P. ' State Work Do I Well Destruction ❑ Well Dia a t Sealing Material b Depthl Depth /r l Filler Material b Depth } TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No 6 septics stem ermiitdd if Y P public sewer is � available within 200 feet.) I Installation will serve: Residence �* Commercial Other Number of living units: Number,of bedrooms v Character of soil to a depth of 3 feet: Water tab SEPTIC TANK. ❑ Type/M} 1Cn g Capacity N No. Compae depth rtments PKG. TREATMENT PLT. ❑ f d Method o_f 0_isposal' I Distance to nearest: Well Foundation ` 'Property L,ne 1 l � } LEACHING LINE ❑ No. & Length of lines Total length/Site I FILTER BED ❑ Distance to nearest: Well Foundation i Property Lint 1r � � SEEPAGE PITS It Depth r Size '- Number SUMPS Ll Distance to neatest: Well Foundation Property Line 4, DISPOSAL PONDS ❑ 1 1 I hereby certify that I have prepared this application and that the work will be done in accor rules and regulations of the San Joaquin County dance with San Joaquin county ordinances, state laws, and 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 ct�that in the performance of the work for which this permit is issued, I shall em Io tion laws of alifornla." p Y Persons subject in workman's compensa- The applica u t call for a i d ins i coons. Complete drawing on reverse i Sig,ed X Title: Date: R DEPARTMENT USE ONLY Application Accepted by 111 Date Area 2-1 Lf Pit or Grout Inspection by Date- Inspection / ' Date Additional Comments: Applicant - Return all copies:to: San Joaquin County Public Health Services +1 Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 ' FEE AMOUNT DUE AMOUNT REMITTED INFO 1CASH RECEIVED BY DATE PERMIT'NO. . EH 14-2 (HEY. i x si V .f f� I- �7 EH 1I-z6 1 1 E f �. f