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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 it PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f� (Complete in Triplicate) .. I 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. 549 and 1862 and the Rules and Regulations of San q Joaquin County Public Health Services. J Job Address _ Q �,7 � WI City Lot Size/Acreage p� r Owner's Name Address f hone _p O Contractor �.t�L� uL LG _ Address /�.# 2f�� ___License No. Phone 217 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well DISTANCE TO NEAREST' SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION' AGRICULTURE WELL OTHER WELL PITS/SUMPS T ' INTENDED USE. TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing EI Domestic/Private ❑ Gravel Packe d Tracy 'Type of CasingW + '"Specifications c 1 I'1 Public Cl Other n Delta Depth of Grout Seal Type of Grout I i Irrigation —.Approx. Depth r I Eastern Surface Seal Installed by ; Repair Work Dona U Type of Pump H.P, State Work Done_ Weft Destruction ❑ Well Diameter . Sealing Material & Depth Depth I Filler Material & Depth , TYPE OF SEPTIC WORK: NEW INSTALLATION iK REPAIR/ADDITION I 1 DESTRUCTION-0 INo septic system permitted if public Bawer is t .. available within 200 feet.! J Installation will serve: Residence-Commercial_ Other "0., y Number of living units: Number of bedroorvs _ '^ L Water table de ") Character of soil to a depth of 3 feet: depth SEPTIC TANK ❑ Type/Mfg IRR V=64.1 Capacity No. Compartments PKG. TREATMENT PLY. ❑ fi .rr Method of Disposal f11 Distance to nearest: Well &1�1—) Foundation /� Property Line^SLn [� LEACHING LINE '� No. & Length of lines .____� ' _ Total Total T FILTER BED C] Distance to nearest: Well// � Foundation Property Line , SEEPAGE PITS i I. Depth �lj r Si. ' fi Number _ 1' L SUMPS Distance to nearest: well Z-Q&5--t- r-F undation—621 Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and.that the work w!1 be done in accordance with San Joaquin county"ordinances, state laws,-and rules and"regutations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "l certify`ihat 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 of sub-contracting signature certifies the following: "I comity that in the performance of the work for which this permit is issued, I shall employ personssubject to workman's compensa- tion laws of California." s The applicant must call f all r red inspections. Complete drawing on reverse side. �. Signed X � Titla: Date: FOR DEPARTMENT USE ONLY �: ti .. Application Accepted by- Pit Date 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 r 445 N San Joaquin, O Box 2009, Stkn, CA 95201 ! INFO FEE AMOUNT DUE �" AMOUNT REMITTED CK � RECEIVED BY DATE ,,,,,,PEAMIT'NO, . EH ,12srREV.,iwb, �]i1✓ r/7 '(Ti/ // / � I //� 7 Z �G�I�D� E„11.20