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SAN JOAQUIN COUNTY PUBLIC HEALTH "SERVICES ENVIRONMENTAL HEALTH DIVISION 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 end/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. p�3_` Job Address t4lVd CooedRG[ City 14e_'JA i+ot Size/Acreage Owner's Name ' Address C ,R tt) Phone Contractor �" Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION o out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well El DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL---------: PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' r C-1 Industrial ❑ Open Bottom w� Cl.Manteca Dia. of Well Excavation Dia. of Well Casing lA Cl Domestic/Private ❑ Gravel Pack! ❑ Tracy Type of Casing_ Specifications C1 Public la Others. n Delta Depth of Grout Seal Type of Grout I I Irrigation Approx• Depth I I Eastern Surface Seal Installed by i Repair Work Done 0 Type of Pump H.P. State Work Done i Well Destruction O Well Diameter i Sealing Material•& Depth Depth a a at--Piller Material & Depth TYPE OF SEPTIC WORXf NEW INSTALLATION I I EPAIR ADDITION l I DESTRUCTION I 1 iNo septic system permitted if public sewer is = + avitilable within 200 feet.) Installation.will serve: ~Residence= (Commercial JOfher Number of living units: —I_ Number'of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg i 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 ❑ Distance to nearest: Well f Foundation 104- Property Line SEEPAGE PITS 11 Depth .MV _Size_ Number SUMPS Ll Distance to nearest: Well /4104-.- Foundation A _ Property Line_sem T 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 I 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 California." The app licanty2Za,_ '\ I for all required inspections. Complete drawing onrreverse side. Signed )( Title: Date: FO DEPARTMENT USE ONLY Application Accepted by �� Date Area (S) Pi r Grout Inspection by Date —Final Inspection by Date 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 FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIVNO, INFO CA,,SH GSC, • EH 13-24(REV.+i n 5 I d� ZZ ✓ EH 1428 '� -