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SAN JOAQUIN COUNTY PUBLIC"HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 pe PERMIT EXPIRES 1. YEAR FROM DATE ISSUED r t (Complete in Triplicate) i 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 Ordina Jnce No. 51+9 and l6 and the Rules and Regulations of San Joaquin county Public Health Services. / ` I City v Lot Size/Acreage Job Address dl j Phone Owner's Name /�� Address Contrattar" aG Address License No .2o Phone Laos 1 Service wel TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION LI Wt Monitoring Well PUMP INSTALLATION ❑ SYSTEM REPAIR ice' OTHER ❑ 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 SPECIFICATIONS C7 Industri9l. - ❑ Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing Type of Gasin Specifications _SDomOsticlPrivate ❑ Gravel Pack ❑ Tracy 9- I'I Public I3 Other # n Delta Depth of Grout Seal TYp?f�u,o�---- f _ Approx. Depth 4 Eastern Surf ce Seal installed by y� I i IrriBa[ion ,� , Repair Work Done 'Type of Pump H.P. Stats Work Dona! l Well Destruction ❑ Well Diameter } Sealing Material & Depth t Depth Filler Material & Depth TYPE OF'SEPTiC WORK: 'NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I (Noilabsepti sysierri emitted if public sewer is avle Installation will serve: Residence— 4Commercial— Other r Number of living units; Number of bedrooms Character of soil to a depth of 3 feet: Water table depth _ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments - PKG. TREATMENT PLT. ❑ Method of'Disposal Distance to nearest: Well Foundation Property line p LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line s SEEPAGE PITS 11 Depth Size -Number SUMPS GI 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 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 me RR eras 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 appli mu call fbr all r Anspe ns.-Complate-Drawing-on-reverse- ' e.-- Signed X Title: �� w µ _ _Date: �� FOR'DEPARTMENT USE ONLY I Application Accepted by _C&A — �"^��- Date a-a Area 21 L - - Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: t t Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, GA 95201 FEE AMOUNT DUEAMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO rr�ee,�` ,�A . EH 13.24 1REV,I/A 5) -�lv l v ftvy EH 14.26