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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420A k, II P 0 BOX 2009, STOCKTON, CA 95201 S'p;�-6, p PERMIT EXPIRES 1 YEAR FROM DATE ISSU S. p �® (Complete in Triplicate) NL/RQC�FCC�4��j� ��2 Application is hereby made to San Joaquin County for a permit to construct and/or install the0>orR'+Ht t� �9110p�. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1.862 and the Rules an � � of San Joaquin County Public Health Services. Job Address ✓ City�f,,& _ Lot Size/Acreage drev � I Owner's Name Address 1 1 , Phone Contractor Address _Iaas� MYLI.`t 9--91�License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT i7 DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE 'TYPE OF WELL PROBLEMAREA CONSTRUCTION-SPECIFICATIONS' _ - n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing i71 Domestic/Private C1 Gravel Pack L1 Tracy Type of Casing_. Specifications I'1 Public f-I Other F1 Delta Depth of Grout Seal Type of Grout ligation —.Approx. Depth Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump t3�`1 H.P. „__ State Work Done Q, Well Destruction O Well Diameter Sealing Material & Depth N Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is 0 available within 200 feet.) ` Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth J SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, C1 .1, Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.'"& Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line i SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 ttt333 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state )ews, and rules and regulations of the San Joaquin County Home owner or lice sed 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 per to such manner as to beco subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fo ng: "I ce ify at in the ormance of the work for which th' permit is issued, I shall employ persons subject to workman's compensa- tion laws of ' m)a." The ap 'ca 11 to r n ctions. Complete drawing on re rse Signed Title: Date: s FOR DEPARTMENT USE ONLY �j r Application Accepted by Date r Area 1 i Pit or Grout Inspection by Date f=inal Inspection by Date � f -7Z- Additional Comments: , Applicant - Return all copies to: San Joaquin County Public Health Services I Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn,-CA 95201 .I FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'N0, . EH 13-24 IREV.i [��_ EH 14.25 7 32k6