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ti..,< 4 + 4. � + SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION s 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 P i `. 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. Job Address CS 'I City Lot Size/Acreage Owner's Name ' Address ��9:2,W-4 Phone Contractor Address License No.F Phone D TYPE OF WELL/PUMP: NEW WELL. ❑ WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION Oxo ,.. SYSTEM REPAIR ❑ OTHER ❑ Monitoring well 0 DISTANCE TO NEAREST: SEPTIC TANK 4"SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ; AGRICULTURE WELL. OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation Dia.--of Well Casing r [.l Domestic/Private ❑ Gravel Pack ..r. ❑ TracyType of Casing Specifications C1 Public i:1-01her = n Delta 'Depth of Grout Seal Typa of Grout V' I I irrigation Approx. Depth d I Eastern *Surface Seal Installed by �] Repair Work Done [J Type of Pump - / H.P. ' State Work Done O Well Destruction ❑ Well Diameter 1 Sesling'Naterial 6 Depth X Depth {:Filler Material'& Depth O TYPE OF SEPTIC WORK: NEW INSTALLATION ! REPAIRiADDITION I I 'DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence ;1"Commercial_ Othe, Number of living unitsr �Numbei of bedrooms Character of soil to a depth of 3-fees, Water table depth �I 1 ' \ SEPTIC TANK. '�"a O Type/Mfg ' Capacity _ No. Compartments ;E PKG.-TREATMENT PIT.-❑" > Method of Disposal Disiance to nearest: Well 64- Foundation 92Property Line L/ - R l svP 1 LEACHING LINE ❑ No. & Length of lines Total Length/size FILTER BED ❑ Distance to nearest: Well IL Foundation Property Line �i % SEEPAGE PITS 11 Depth _ 4 Size k� Number SUMPS 0 Distance to nearest: Well D-5;1 4Foundation Property kine 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 rules and regulations of the San Joaquin County i i r Home owner or licensed agent's signature cenifietthe 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-l'shall-employ persons subject to workman's compensa- tion laws of California," `•. ;t The applicant must Call for all required inspe do s. Corn'plete drawing on reverse side. Signed Title: � Date: F Rpm -QEPARTMENT USE ONLY A plication Accepted by N 31 Qkbm= Date _ L iO^ !�A►ea Or Grout Inspection bf Final Inspection by Date7--_-4 'Z 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 FEE CK if I INFO AMOUNT DU( AMOUNT REMITTED CASH RECEIVED BY DATE PERIvirr'IVO. FH 14-20 17, " - I