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sAN •1QUIN COUNTY PUBLIC HEALTH . VICES TH -q ENVIRONMENTAL HEALTH DIVISIt 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 tsade to tan Joaquin County for a permit to construct and/or install the work herein described. This application in *Ads in costpliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �'7� �. r CitylgdPW Lot Size/Acreage Owner's Name t Q�r l �_ Address S�4�'X1(1 r 953hone 1." 1 Contractor Address CA%60 1 �b License No.�944} TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT n DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Cl Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Pq Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation A Dia. of Well Casing Cl Domestic/Private )ieGrsvel Pack C1Tracy Type of Casing_ Specifications I'I Public Cl Other n Delta Depth of Grout Seal _^— 4D Type of Grout d' I I Irrioation —110a�Approx, Depth I I Eastern Surface Seal Installed by. Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 lest.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of Will to a depth of.3 feet: Wato.Z,ZG6fl1i1ED SEPTIC TANK O Type/Mfg Capacity NlaPKG. TREATMENt PLT. ❑ Distance to nearest: Well Foundation Property L 2 LEACHING LINE ❑ No. A Length of lines Total lengt 1 FILTER BED ❑ Distance to nearest: Well Foundation �f�U�ttC-hTAt-H&444H DIVISION�t►��lAt4MlLntT^'�^.t;,'-i DIVISION SEEPAGE PITS If Depth Size Number SUMPS LI Distance to nearest: Well Foundation_ Property Line 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 Home owner or licanssd 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 workmen's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I Certify that in the performance of the work for which this permit is issued, I$hall employ persons subject to workman's compensa- tion laws of California." The applicant must Call for all r quired spA tions. CompletA drawing on reverse ids. Signed X Title: Date: _ R DEPARTMENT USE ONLY Application Accepted by y- Date— 2 Area _ Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED 9V INFO DATE PERMIT'NO. • EH 1324IaEV.iin5t�ti1 p FH 14.2$ ��// !7