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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 7"- ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 I PERMIT MIRES 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. IF„ Job Address _.. �t,' c �Q� City Lot Size/Acreage /1 H1X I Owner s Name I/�Cf�.�(1 ( Addressr �' !f` t` Address .�.� Contractor License TYPE OF WELL/PUMP: ..NEW WELL ❑ WELL REPLACEMENT DESTRUCTION,, Out of Service Well ❑ PUMP INSTALLATION 0 ` SYSTEM REPAIR ❑ OTHER LJ Monitoring Well C DISTANCE TO NEAREST: SEPTIC TANK _122 1 SEWER LINES 12—e r,p� DISPOSAL FLD. r PROP. LINE IM FOUNDATION AGRICULTURE WELLd}� OTHER WELL PITS/SUMPS �I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial I�; p Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private CE�-4ravel Pack 0 Tracy Type of Casing_ �G 1 25r>Bcifications 1'I Public I f_1 Other D Delta Depth of Grout Seal 7 �y erof Grout I I Irrigation I. cF�Approx, Depth- I I Eastern Surface Seal Installed by ttl�' 1S 1 } Repair Work Done, 0 Type ype of Pump H.P. State Work Done , Well Destruction C) Well Diameter Sealing Material & Depth Depth Filler Material & Depth jt TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITtON I I DESTRUCTION [ I iNo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other uNumber of living units: Number of bedrooms Character of soils to s depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ +. .� Method of Disposal �- Distance to nearest: Well Foundation Property Line - v LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line f r SEEPAGE PITS 11 Depth Size Number f SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 shalt not employ any person-tin such manner as to become subject to workman's compensation laws of California." Contractor's 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 California." The applicant m scall for all required inspections. Complete drawing on reverse side. ` Signed Title: Date': FOR DEPARTMENT USE ONLY A pplication'Accepted by Date � /+Area Pitrout 64ic:lion by Date 'na lnspection by Dat 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 tFEE'� AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'No. 475 y_ 3- 1'09",� e . EH i3-24{REV.114 S4571 EH i44e