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SAN JOAQUIN COUNT'.. PUBLIC HEALTH SERVICES ENVIRONMENT HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED wt`� eP� � (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 1 2 and the Rules and Regulations of San I Joaquin County Public Health Services. i R Job Address 3 " City Lot Size/Acreage Owner's Name / Address N� Phone Contracto �. Address icense N_23_ l0 Phone o` TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F.1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER 17 Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS s INTENDED USE TYPE OF WELL ,,PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom [I Manteca Dia. of Well Excavation Dia. of Well Casing `K Domestic/Private ❑ Gravel Pack7 0 Tracy Type of Casing_ Specifications I'1 Public 0 Other F1 Delta Depth of Grout Seal Type of Grout I ) Irrigation —Approx, Depth I Eastern urface Sedl Installed by 00 Repair Work Done Type of Pump H.P. State Work Done_ Q-C,12F� Well Destruction ❑ Well Diameter t Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION 11 (No,septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other `'� V 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.0 1 Met3 hod of Disposal Distance to nearest: Well Foundation ;Properly Line L i LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth 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 nol employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature certifies the following: "1 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 Calif or ia." a i The applies ust ll for all re uir i ctions. omplete drawing an reFir side. CC n Signed.K G Title: ___ i" Data: Sa m DEPARTMENT USE ONLY Application Accepted by AM - a=P A-A eb ef!i, -- -- Date —q---ZS Z9 Z— Area - �7 v Pit or Grout Inspection by Date Final Inspection by��-rLa'� Date Additional Comments: 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. FEE AMOUNT DUE AMOUNT REMITTED CK ECEIVED BY D INFO E PERMIT'N0. . EM3.24IREV.rin51 EH 1446 tit !