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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 �I P 0 BOX 2009, STOCKTON, CA 95201 I II "i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) f Application is hereby made,ito San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance Vith San Joaquin County Ordinance No. 549 and 1662 and t e Rules and Regulations of San Joaquin County Public Health Services. Job Address Cit of Size/Acreage r f� �'v}� `�f ew rC Owner's blame� �'` � Address �0 'IT � � Phone � 7 A 077 04 Contractor AIL/�/ ddress '% ` License No.- � -Phone P P P: rra -- TYPE Of WELL/ U NEW WELL C1 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well G1 . 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 ._ ,F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �_L7-1,ndustrial •-O-Open Bottom.o.a.,-- -❑ Mantecas..- -. Dia.-of:We11-Excavation - Dia. of Weil Casing Cl Domestic/Private ❑ Gravel.Pack ❑ Tracy Type of Casing_ Specifications I'I Public f-1 Other f-} Delta Depth of-Grout Seal Type of Grout I # Irrigation _Approx• Depth I I Eastern Surface Said Installed by � Repair Work Done L7 Type of Pump H.P I !Stats Work Done �1N 11 estruc`t, ❑ Well Diameter - Sealing'.Ifaterial Depth 0 'DepthM - ' Filler Material 5 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRlADDITION i I �DESTRUCTION-1 I (No septic system permitted if public sewer is i J t available within 200 feet.l `} i Installation will,serve: Residence— Commercial � ief_".. ~� Nu`mber"of•living units: Number of bedrooms'_ Character of soil to a depth of 3ji- feed '• Water cable depth j SEPTIC TANK - - _ . ❑ Type/Mfg - - -Capa'"y �� 0 No::Compartments PKG. TREATMENT PLT. ❑ A 2-11Aethod-of°Disposal p -�- Distance to nearest: We11lO0 Foundation. j Propert.yr Line LEACHING LINE Cl No.'I& Length of lines �"'"' � "-" "Totai'lengtls7slze r FILTER BED ❑ Distance to nearest: Well �yd�r Foundation _/ Property Line 5 ,..,_,. - ��. SEEPAGE PITS [ I Depth Size Number ~� ++�•7r � SUMPS Distance to nearest: Well /t3jC_ Foundation� s,t` Property Line DISPOSAL PONDS ❑ I ' I hereby certify that I have prepared this application and that the work will be done in accordance with '"n,Joaquin county ordinances, state laws, and'4-. 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: "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 must call for all r �'a inspections. C plete drawing on reverse side. `7J YZSigned Title: &11Date: I� I� FOR DEPARTMENT USE ONLY K p Ic n A Iogqccepted by ' Date Area P' ohlt�action by at17 Final inspection by • Date s Additional Comments: I'pr r' Applicant - Return a1llfoopies to: San Joaquin County Pubi c Health Services Environmental Health Permit/Services X445 N San Joaquin, P0 Box 2009, Stkn, GA 95201 INE AMOUNT DUE AMOUNT,REMtTTED CK 10 RECEIVED BY DATE PERMIT'NO. EH 1 � // ♦ 3-24 lREV.I/x 5i 4.l� ® ' EH 14.75 or it Ih