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E SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 mads to San Joaquin County for a permit to construct and/or install the work herein described. This application 1s made in compliance withSan Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �D�2 / ! +� City 5;7- hot Size/Acreage Job Address �` ��'p � C / -( kwner's Name 14/ i Address _ J �e I 'r' Phone�� /�'.�(P �antractor SF Address License No. Phone TYPE OF WELL/PUMP: NEW,WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well C PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SPOSAL FLD. PROP. LINE FOUNDAT•i0 I AGRICULTU L OTHER WELL PITS/SUMPS f a INTENDED USE TYPE OF WELL PROBE EA CONSTRUCTIaN ECIFIC-A7JONS n Industrial O Open Bottom (`Manteca Dia. of Well Excavation Dia. of Well Casing Q [I Domestic/Private ❑ Gravel Pack r El Tracy Type of Casing_ Specifications I'1 Public (=1 OtSer C1 Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by 4 �) 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 REPAIR/ADDITION I I DESTRUCTIO lNo septic system permitted it public sewer is silable within 200 feet.) Installation will serve: Residence_ i Commercial ____ Other 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. ❑ t Method of Disposal Distance to nearest: Well Foundation Property Line 1 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS 11 Depth E� 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 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 I employ any person in such manner as to become subject to workman's compensation taws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which Nos-permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." I The applicant rnugk call for all required insPections. Complete drawing on r verse side. Title: /E' - Date: igned X Ks - FOR EPAR ENT USE ONLY �9� 4r 71 Application Accepts - Date Area Pit or Grout Inspection by Date Final Inspection by Date f Additional Comments: i 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 i FEE AMOUNT DUE _�AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. IN++rrFO--H . EM 13.24IREV. �� EH 11.26