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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. t 2X1 7 A!+ � ` Joh Address "� [ City ()��fkffjlWT.ot Size/Acreage Owner's Nam Address Phone _9 -32 ILI Contracto Address n I License No.SZZ Z(v Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring well L� 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing {.l Domestic/Private Ci Gravel Pack El Tracy Type of Casing_ Specifications i'1 Public Cl Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done LJ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ( 1EPA !ADDITION DESTRUCTION I I iNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other r Number of living units: _/_ Number of b ro ms �� f Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. Cl Method of Disposal Distance to nearest: Well Foundation Property Line q0 q0 LEACHING LINE No. & Length of lines Total length/size k FILTER BED ❑ Distance to nearest: Well So r Foundation 41Property Line SEEPAGE PITS Depth Size lumber SUMPS LI Distance to nearest: Well 100/ Foundation 0- 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 subcontracting 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 st call for r red inspections. Complete drawing on reveer s t Signed X Title: U 4 Date: :20 9.5 FOR DEPARTMENT USE ONLY `q Application Accepted by Date 2,3 JArea r Grout inspection by 410=Le e Date Y_f_L�_qFinal Inspection by -7, 17-D Data!k3 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK aCASH r�REECEIVED BY r��pA�DATE PERMIT'NO. . EH 13-201t1EV.iiHSY /) - C, Qv J i /- �/J V FH u•le /'e J