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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMMTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT. RES l YE FR M DATE ISSUM (Complete in Triplicate) Application is hereby made_to San Joaquin County for a permit to construct and/or install the vork herein described. This application in made in coatplionce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San U Joaquin County Public He th Service AL City Lot Size/Acreage Job Address Phone ,J_/ Address Owner's Name 1 I 05 Phone Contractor — Address 1 OQ t•`�� License No. TYPE OF WELLlPUMP: NEW WELL O WELL REPLACEMENT .1 DESTRUCTION Cl Out of service Well PUMP INSTALLATION O SYSTEM REPAIR OTHER O Monitoring Well C- r SEWER LINES ._--- DISPOSAL FLO. PROP. LINE DISTANCE TO•NEAREST: SEPTIC TANK PITS/SUMPS — y -L ; FOUNDATION AGRICULTURE WELL. OTHER WELL— w l 11 INTENDED USE TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS i y Dia. of Well Casing �f_1 Industrial l G Open Bottom ❑ Manteca Dia. of Well Excavation specifications Pv Domestic/Private ❑ Gravel Pack ❑ Tracv '.Type of Casing_._-- / (-1 Delta Depth of Grout Seal 1- Type of Grout 1 Public I 1 Other r I IrriUation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump �U� H.P. 11 State Work Done F C4. Sealing Material li Depth Well Destruction O Well Diameter r P i Depth Miler Material i Depth (No septic Wslern permitted TYPE OF SEPTIC ORK: NEW INSTALLATION t I REPAIarADOITION I ! DESTRUCTION I I available w thin 200 feet.1 if public sewer la W t Installation will serve: Residence— CornmercW— Other I Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 lest: r F No'Comparmdnts Capacity SEPTIC TANK O Type/Mfg II l • Method of,Disposal PKG. TREATMENT PLT.O i I1 J� r11 t a Distance to neareft: Well-_.Foundation- .Foundation Property Line 4J ; Total length/size�� t LEACHING LINE D No. is Length of.lines � ^ FILTER BED � ❑ Distance to nearest: 1 WPFoundation Properly Line — size , 1 • ' �l Number SEEPAGE PITS' 11 Depth Siie i - ' / ' ll Distance to nearest: Well ~� / Foundation Property Line r SUMPS= _ ct`- '+5 `DISPi5SACPONDS Off' ` I hereby certify that I have prepared this application and that the worse will be done in accordance with San'Joaqui_c�nty ordinarica�,state Paws, and rules and regulations of the Sen Joaquin Countywhich this.permrt is ued. 1 shall not 4 Homs.owner or 'tensed agent's signature certifies the following: "I certify that in the performance of the work for iss employ any . iri such manner as to become subject Io workman's compensation laws of California."Contractor's hiring or sul'contracting signature certifies the f owi : -I certify that in the performance of the work for which this permit rs issued, I shall employ persons subject to workman's compensa- 1 tion Is of - ` The a a st call for all r uired ins ti ns. Comdata drawing on ev l / Date: r Signed Xy' Title:) _ I — ~- ~FO DEP—RTME USE ONLY r -^ Date -3o Z Area — Application Accepted by ��l u u Data �� Z Pit or Grout Inspsction'by Date Final Inspection by I� r Additional Comriisnts: Applicani - Return all copies-to:" San Joaquin County Public Health Services ii,-iii ; Environmental Health Permi t/Services Ii [ 'a �• y' J' '� 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 , "' . �•. �..e tom; FEE tt RECEIVED BY DATE PERM11 NO. INFO AMOUNT DUE AMOUNT REMITTED CASK . EH tY74(REV.s/gs io � EH 1448 r