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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 T PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ,r 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 Joaquin County Public Health Service . Job Address City hot Size/Acreage t Owner's Name as Phone Loe f (� Contractor 177e 's iCense No, Phone TYPE OF WEL /P P: NEW WELL WELL REPLACEMENT F.V DESTRUCTION out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C ' Monitoring Well C7 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 - D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private . ❑ Gravel Pack El Tracy Type of Casing_ Specifications t I'I Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth' l l Eastern Surface Seal Installed by f - Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Wall DiameterSealing Material & Depth Depth Filler Material pth F- TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAMIADDITION iff DESTRUCTION l I (No septic system permitted if public sewer is available within 200 fest.1 Installation will serve: Residence_ Commercial_ Other F Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth r SEPTIC TANK 0 Type/Mfg Capacity No.,Compartments PKG. TREATMENT PLT. ❑ ,a Method of Disposal k Distance to nearest:- Well 7O Foundation Property Line_r� F LEACHING LINE D No. & Length of lines Iry Total length/size FILTER BED ❑ Distance to nearest: Well !70 Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI . Distance to nearest: Well Foundation Property Line ' DISPOSAL PONDS 0 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, an rules and regulations of the San Joaquin County r. k..- 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: "I 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 ;Mf c r a require t s ctions. Com to drawing on averse side. /� Signed Title: J Date: Y FC69 DEPARTMENT USE ONLY 4_1 Q �f Application Accepted byADate�,0 !Z— Area d Pit or Grout Inspection by Date Final Inspection by W r Date -i 2 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. . EH 17.21(REV.Ii x si [►;' EH14-26 14-26 �/�