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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P 0 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 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. ^/ f Job Address City�. u'1 Lot Size/Acreage Owner's Name �'L' - AddressPhone 0670 Contractor "—Address 6o 13 10442d, sa No.;67D.1 IPhone J TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F.1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 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 SPECIFICATIONS C71 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public CI Other f1 Delta Depth of Grout Seal Type of Grout I i Irrigation Approx. Depjh�f. I I Eastern Su ace Seal Installed by Repair Work Done L3 Type of Pump s� H.P. �• State Work Don u�- Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial _ Other rj Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth rp SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line jl LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line - -, SEEPAGE PITS 11 Depth Size Number IL 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 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 applicant mus II f=Anspe:ctions. Complete drawing on raver de. Yc 1 Signed X Title: J[.�•Sd1 _ Date: F R DEPARTMENT USE ONLY J f { Application Accepted byDate 1� Area Pit or Grout inspection by Date Final Inspection by��A . _ata Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services FEENT DUE AM 445 N San Joaquin, P D Box 2009, Stkn, CA 95201 INFO MO NT UNTJ]REEMITTED CASH RECEIVED BY DATE PERMIT'No. • EH 13.24(REV.rims �� "- [ ` j 2 i q3 O r EH 1446 r T-f r I _ 1