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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �7 , ENVIRONMENTAL HEALTH DIVISION J 445 N SAN JOAQUIN, PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR 'FROM DATE ISSUED � G2 ul (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 trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Couniy�JPublic Health Services. KJob Address ! �._ N C� T7 (,j d so City t v Lot Size/Acreage Owner's Name� n- - ��i�IV--VAddress � - lQ fir`1 l (U - Phone a �- �pII ,� o Contractor�1�� _ Address License No. _Phone ,TYPE OF WELLII/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-7 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ 'SYSTEM REPAIR ❑ OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP. LINE IT FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED PSE TYPE OF WELLS PROBLEM AREA- CONSTRUCTION SPECIFICATIONS Cl Industrial jl� ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing (a Domestic/Private 0 Gravel Pack D Tracy Type of Casing_ Specifications I'1 Public Cl Other 11Delta Depth of Grout Seal Type of Grout { A I Irrigation �..Approx. Depth t 1 Eastern Surface Seal Installed by ^� Repair Work Done ❑ Type of Pump H.P. State Work Dona Wet(Destruction�sI O Welt Diameter Sealing Material & Depth QIP Depth Filler Material & Depth TYPE OF SEPTI' WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Z.. Installation will serve: Residence T Commercial_.—,. Other 1. Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK l� ❑ Typo/Mfg Capacity No. Compartments s PKG. TREATMENT PLT. Cl < Method of Disposal Distance to nearest: Well foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED �f ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITSJ� 11 Depth Size Number SUMPS 0 LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r 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 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 Calif nis.' Theapplicant I� call for all requir itpactions. Complete drawing on r verse side. / [ Signed Title: F Dater- � �� OR 9 ARTMENT USE ONLY t Application Accepted by CQ .A -- Date Z Area ` Pit or Grout Inspection by Date u� Final Inspection by Date Additional Com�llments: Applicant�l- 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 CK 0 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. a EH19-21(REV:t i x 5) � r D O C/r7�jt 5-!9 !2 V l EH 11.20 L v !