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,. SANI,-JOAQUIN COUNTY PUBLIC HEALTH SERVICES E� ERVIRONMENTAL HEALTH DIVISION 445"u, SAN JOAQUIN, PHONE (209)468-3420 P '0 BOX- 2009, STOCKTON, CA 95201 j pERMIT MIRES 1 YEAR FROM DATE ISSUED � (Complete in Triplicate) made to San Joaquin Countr.for a permit to construct and/or install the work herein described. This E application Application is hereby Ordinance No. 549 and 1862 and the Rules and Regulations of San k appllcatioA fa made in compliance with San Jo Joaquin Joaquin County Public Health Services. 4 � � 14 wCity Lot Size/Acreage 1 Job Address R� Phone Address t Owner's Name f Address REPL WENT Cl License No. o Phan -Contractor... - - - - DESTRUCTION Cl Out of Service•Well ❑ NEW WELL ❑ WELL Monitoring Well ❑ TYPE OF WELLlPUMP: SYSTEM REPAIR ❑ OTHER ❑ { PUMP INSTALLATION ❑ fSEWER LINES -- DI5PO:AL FLD. PROP- LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS FOUNDATION �� AGRICULTURE WELL OTHER WELL— INTENDED USE - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of 11Vei1 Casing ❑ Open Bottom O Manteca Dia. of Well Excavation El Industrial Specifications ❑ Tracy Type of Casing_ [a Domestic/Private ❑ Gravel Pack Depth of Grout Seal i'1 Public �T,ype of Grou I'l Other n Delta Surface Seal Installed by I i Irrigation �Approx. Depth I I Eastern of Pump H.P. State Work Done U - ' Repair Work Done Type Sealing Material & Depth ' Well Destruction ❑ Well Diameter I Depth Filler Material &Depth 1 TYPE OF SEPTIC WORK. NEW INSTALLAT40N I I REPAIRIADDITION DESTRUCTION I I availablerif public sewer is within 200 fiat.) 4: Installation will serve: Residence— Commercial ____ Other — Numher of living units: Number of bedrooms , � � Water table.depth Character of toil to a depth of 3 feet: No. Compartments SEPTIC TANK ❑ Type/Mfg Capacity-- I'"- �' Method of Dispose! PKG. TREATMENT PLT. ❑ {i t`_f -- Property line Distance to nearest: Wel! �� Foundation r„Yt Total Iengthlsize LEACHING LINE Cl f No.-& Length of lines . Well Cl Distance44o nearest:-- �� Foundation �� "Property t FILTER BED � � ' SEEPAGE PITS ; I 1 Depth 1 !Size r^ f Number f •Distance to nearest: Well 5 Foundation -f - Property tine I tr SUMPS DISPOSAL PONDS - Q ^1 E I `be done in accordance with San Joaquin county ordinances, stat la s,°and hereby certify that I have prepared this application and that the work will 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;1 shall not k employ any person ih such rnanner as-to-become subject to workman's compensation laws of Cafifornia.” Contractor's hiring or sub-contracting signature for which this permit is issued;I shall employ persons subject to workman's compo risa- eertities the following: "I certify that in the per#ormanca of the work tion laws of California." +. _ The applicant all for all r rr nspect! s. Complete drawing on reverse side. ' l Title: Dots: Signed ' DEPAHTMEN7 USE ONLY I 77 l — l ��FOR �� '�v Area — ! Application Accepted by Date Date ate �� Final Inspection by T ,, or Grout Inspection by �M T 11 } L Additional Comments: a 1 I Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services , , .-------_.•�--445-.N-San Joaquin-,_P O!„9ox_2009_,-,Stkn,. CA 9520 w � FEE CK RECEIVED-9Y ` DATE PERMIT NO. ' INFO AMOUNT DUE AMOUNT REI4tITTEO � CASH \ v I . Eh :�+744REV.y�we1 EH 11.20 .ti^_� ' r