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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 made.to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health iServices. Job Address _Z•� �� / --- �`-�7-� City Lot Size/Acreage Owner's Name Address Phone Contractor GL Address /mat d License No.. sfdff.2 Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation _ Dia. of Well Casing is Domestic/Private Cl Gravel Pack Cl Tracy Type of Casing Specifications t i'1 Public 0 Other Cl Delta Depth of Grout Seal Type of Grout I Irrigation Approx- Depth I I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. State Work Done r Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence'eCommercial Other 1 Number of living units: _�__ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth "J SEPTIC TANK 13Type/Mfg Capacity ' No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundat�'pn �property Line LEACHING LINE 0 No. & Length of lines Total length/size 0 FILTER BED �' Distance to nearest: Well Lfd—Foundation Property Line FT SEEPAGE PITS 11 Depth Size — Number VVV SUMPS Ll 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 employ any person in such manner as to become subject 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 persons subject to workman's compensa- tion laws of California." The applicant must call for $II requi ed inspections. Complete drawing on reverse side;" Oil Signed x ` Title: _ z2*�*,1f ` Date: FOR DEPARTMENT USE OICLY Application Accepted by Date g T 2 Area Pit or Grout Inspection by Date Final Inspection by 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 REMITTERCK RECEIVED BY i DATE PERMIT'N0. INFO / / • £H 53.24 IREV.i/A 5s 'Sk / � �/�� EH tl-2e