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SAN JOAQUIN COUNTY PUBLIC*,HEALTH SERVICES ENVIRONMENTAL `HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 4 P O BOX 2009) STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 1$62 and the Rules and Regulaions of Ban Joaquin County Public Health Services. � a Job Address � � � d_Z1r_a_ City Lot Size/Acreage Owner's Name dPhone 17Q dress OrT j�h Address �T "�` License Na. Phone TYPE OF W LL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER EIMonitoring 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 n Industrial ❑ Open Bottom ❑ Manteca rr Dia. of Well Excavation Dia. of Well Casing { n to Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing— Specifications— F) pecifications I'I Public (:1 Other, n Delta Depth of Grout Seal Type of Grout j ii Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done 1J� I Weil Destruction ❑ Well Diameter paling Material b Depth Filler Material III Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIR/ADDITION I I DESTRUCTION I i iNo septic system permitted if public sewer is r available within 200 leet.l Installation will serve: Residence...�. Commercial Other 7 rn Number of living units: __J_ Number of bedrooms Character of soil to a depth of 3 feet: _ v`. —r- Water table depth SEPTIC TANK. ❑ Type/Mfg 3L Y= Capacity0 No. Compartments PKG. TREATMENT PLT. 0 r kA Method of Disposal Distance to nearest: Well D Foundation iL Property Line I r LEACHING LINE C1 No. & Length of lines �-" Total length/size 4 FILTER BED n. Distance to nearest: Well-may _A—Foundation Property Line _J6W_ �? SEEPAGE PITS I I Depth O r .S Number esvunpl Ll Distance to nearest: Well __ Foundation_Ja Property Line DISPOSAL PONDS ❑ 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, and rules and regulations of the San Joaquin County 3 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: "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." r The applicant must call for Ire uired inspections. omplete drawing on reverse side. ri �rl—g# Signed % A Title: Date: Y FOR DEPARTMENT USE ONLY Pf Appli Ion Accepted by Date �" Area Grout ction by / Date I inal Inspection b Date ��' Z, �� g f Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY _ DATE PERMIT'NO. INFO f p q • EN 13-24 IREV.1/M 51 ! J yr mid * � � 7 L � ? EH 14.2E