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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 2 445 N SAN JOAQUIN, PHONE (209)468-3420 "!D P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 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. 51+9 and 1862 and the Rules and Regulations of San mp Joaquin County Public Health Services. I �aq,�rl `rf � 'd _ City Lot Size/Acreage 4 9�' Job Address Uu !! c lire Address S9` 1 23 Y,,4 r . Phone Owner's Name _ Conlraclor A) Address ' License No. 771�ela Phone — I, TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT F1DESTR O TIOX� Monitoring Well C1 Of Service Well G1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �ER DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications [] Domestic/Private Ci Gravel Pack � ❑ Tracy Type of Casin g-- Type of Grout I'l Public I:1 Other I-1 Delta Depth of Grout Seal I I Irrigation -&AL ZP%oPLApprox, Depth I I Eastern Surface Seal Installed by M Repair Work Done ❑ Type of Pump f H.P. Stat-q work Don r. Sealing Material & Depth Well Destruction $E Well D- to Depth f Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system permitted if public sewer is 0<0available within 200 feet.1 Installation will serve: Residence_ Commercial Other - .t Number of living units: Number,of bedrooms Water table depth Character of soli to a depth of 3 feet: SEPTIC TANK- ❑ Type/Mfg I Capacity No. Compartments I� PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 111 - I LEACHING LINE Cl No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line } SEEPAGE PITS 1 I Depth Sire Number � SUMPS L1 Distance to nearest: Well Foundation - Property Line DISPOSAL PONDS ❑ l -� I hereby certify that I have prepared this application and Fthat 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 subfect,to workman's compensation laws of California." Contractor's hiring,or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion laws of California." I ` The ap cant m t call for a -eq ad inspections. Complete drawing on reverse side. Signed d-� Title: 4 Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �!� Area Date Fin Inspacti by Date cql Z Pit or Grout Inspection by � � � Additional Comments: 4SO& �p P Applicant _ Return all copies to: San Joaquin County Public Health Services TO*- Environmental G �gr j Environmental Health Permit/Services ct /�y�/C. !] 11 445 N San Joaquin, P O Box 2009, 8tkn, CA 55201 J( FEE AMOUNT DUE AMOUNT REMITTED CK A CASH RECEIVED BY DATE PERMIT NO. � , INFO �/� /� -je c ( /J y/�� ♦ EH 13.24IREV.1/a Si" 106 � e � i &1r, p'��"`�' Pat— EM 14.26 _ ,- (yk- 321 30`35 11" (Zf--