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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 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 '�-�^ `A City ' Lot Size/Acreage 339•-y1 0S Owner's Name Address — - Phone Contract J my Address 1 .�. L�f�lt` I ( ! :d�za License NoG Phone b —510T TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well Ll 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 C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack7 Ll Tracy Type of Casing_ Specifications I'i Public C7 Other f1 Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAt ADDITION-K-- i I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence e Commercial_ Other , Number of living unite: _.L._ Number of rooms Character of soil to a depth of 3 feet: Water labia depth vl SEPTIC TANK. * Type/Mfg Capacity _ No. Compartments PKG. TREATMENT PLT. Cl +t / ""Method of Dilposal Distance to nearest: _ Well SO Foundation Property Line S _T LEACHING LINE Cl No. & Length of lines {` Total length/size FILTER BED x ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS X Depth r95____ —S i" Number / f SUMPS Ll Distance to nearest: .,` Well Foundation __ _ Property Line DISPOSAL PONDS ❑ 1 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 i all for alMu d inspections. Complete drawing on reverse side Signed X Tills: .._ 1�. r Date: I's FOR DEPARTMENT USE ONLY 7I- Af Application Accepted by Date ArearJ It r Grout Inspection by / ate Final Inspection by ��Lr ,�t__ Date Additional Comments: Applicant - Return all copies to: _San ,J.oaquin_County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P Bo)f 2009, Stkn, `CA,95201 i. FEE AMOUNT DtJ AMO NT REMITTED 101 CK RECEIVED 8Y DATE PERMIT'NO. INFO . EM t3-241REV.11145I l ! IT— Eat 14.2E