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Pib' SAN JOAQUIN COUNTS.# PUILI'C HEALTH SERVICES r' ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 cx 11vL� �t S C 1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in, Triplicate) Application is hereby toads to Sam 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 Count Public Health/Services � -/ Job Address _ � f ! -E ti]a� „r,Cr d1 ,� �Q city L' Lot,Size/Acreage el V& � I Owner's Nam P cr /)address �" Phone Contractor I AddresO �c�` ' re License Ntt e Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Ll Out of.Service Well ❑ i PUMP INSTALLATION SYSTEM REPAIR 0 OTHER 0 Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL_ FLD. PROP. LINE FOUNDATIONr) AGRICULTURE WELL OTHER WELL PITS/SUMPS r. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial I3 Open Bottom 0 Manteca Dia.:of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications 0 I'i Public (D Other n Delta Depth of Grout Seal Type of Grout i I Irrigation _.Approx. D pth 1 1 Eastern Surface Saul Installed by Repair Work Done X Type of Pump` H.P. _ __ State Work Done r r V" ' Well Destruction ❑ Well Diameter f Sealing Material & Depth Depth a Filler Material & Depth R TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ! I DESTRUCTION I I (No septic system permitted if public sewer is ? available within 200 feet.)- Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: 9 Water table depth SEPTIC TANK ❑ Type/Mfg ) Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line S LEACHING L LLNE'` ❑ No. &.Len th of lines. g 7otallength/sire � I FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth ? -Size Number SUMPS CI 1 bistance to-nearest: well Foundation � Property Line DISPOSAL PONDS ❑ t 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 shall not employ any person in such manner as to become subject to workman's cbmpansation laws of California." Contractor's hiring or sub-contracting signature 1 certifies the following: "I certify that in the performafce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif The ap t must a .. or all require pecti Complete drawin rse side, Signed X Title: Date: /4�; FOR DEPARTMENT USE ONLY Application Accepted by Date — Z gree �- Pit or Grout Inspection by Date Final Inspection by Dste 6 g U 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 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. Ji . EK1A3.21 IREV.i i n yl EH 11.26 PA) r