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1 f 7 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 u (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 I Joaquin County Public Health Services. f Job Address (�Cily Lot Size/Acreage ._O►GS Owner's Name �oZa Address O yfto l Phone -� a D(Contractor a t.t)6 Qt _Address! � S��--License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REP ❑ OTHER C3 Monitoring Well 4 DISTANCE 70 NEAREST: SEPTIC TANK SEWE LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL URE W E L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA ON RUCTION SPECIFICATIONS ' C7 Industrial ❑ Open Bottom ❑ Manteca Di of Wel! Excavation Dia.'of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy yps Casing_ Specifications I i'1 Public C1 Other Cl Delta Depth of out Seal Type of Grout Q I Irrigalion —Approx. Depth l I Eastern Surface Saul tailed by Q Repair Work Done 0 Type of Pump ," P. _� State Work Done r Well Destruction ❑ Well Diameter r Sealing Material & Depth ` Depth Filler Material & Depth I TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR-/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is f available within 200 feet) Installation will serve: Residence—4 Commercial Y Other Number of living units: , �l Number of-.b drooms Character of soil to a depth of 3 feet: ttr D fy - Water table depth SEPTIC TANK D Type/Mfg Capacity. _ No. Compartments : PKG. TREATMENT PLT.Ll �� Methpd of Disposal Distance to nearest: Well Foundation _ Property LinetL LEACHING LINE Cl No. & Length of lines'' r Total length/size d 2' s o FILTER BED ❑ Distance to nearest: Well Foundation _ Property Line r � + SEEPAGE PITS 11 Depth + Size Number SUMPS CI Distance to.nearest: Weil (o `_ Foundation Property Line I Po 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: 1 certify that in the performance of the work for which this permit is issued,.f$hail not employ any person in such manner as to become subject to workman'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 shall employ persons subject to workman's compensa- tion laws of California." The ape' ust call for all required inspect' s. Complete drawing on reverse side. : 7-g X-5igned x Title: 0, Date: i 'OR DEPARTMENT USE ONLY Q{ Application Accepted by Date ^9 Area O Pit or Grout inspection byDate Final Inspection b Date Additional Commentr. Applicant - Return all copies to: San Joaquin County Public Health Services Environmental j Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO jl CASH . EH 13-24 MEV.i/A S! EH 1♦-25 i