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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)458-3424 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FR M DATE ISSUID r (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is rade in compliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r /�� Lot Size/Acreage L r� �� - %vim Dei City Job Address Phone Mtg - o , Address Owner's Name Address Contractor Iducense No. O hone l� TYPE OF WELL/PUMP: 4L . DISTANCE TO NEARED NEW WELL ❑ WELL RE ACEMENT n DESTRUCTION ❑ Out of Service well Li❑ Monitoring,Well, PUMPS INSTALLATION ❑ i ,SYSTEM REPAIR Od OTHER 'O ', r: SEPTIC TANK. SEWER LINES DISPOSAL FLO. PROP- LINE - GRICULTURE WELL OTHER WELL—PITS/SUMPS i — FQUNDATION A , I.= INTENDED USE TYPE�LL 1 PROBLEM AREA' CONSTRUCTION SPECIFICATIONS �Oia.,of-Well Casing ❑ industri� of Q Open Bottom ❑ Manteca Dia. of well Excavation Specifications [.} Domestic/ Private CJ Gravel Pack Type of Casing_ C] Tracy TYpe of Grout Depth Grout Seal ' i"} Public ` f71 Other { ! I ' f l Delta ,, t l I Eastern�'1 -N -Surface So Installed by I I Irrigation Approx. Depth / State Work Done'+ Repair Work Done U Type of Pump Sealing material Depth t Well Destruction CJ Well Diameter Filler Material b Depth ; ` TYPE OF SEPTIC WORK; Depth ri _ . NEW INSTALLATION I I REPAIR'/ADOITION DES7 [ON I{ aNailabletrw�ith 2y0�4 faet�jrm-ed if public sews+ is t Installation will serve: Residence ____-. Com41 'Y' �� Other w A r Number of living'.units: Number of bedrooms ,,, f : E -r Wa er table depth f Ch t r of soil to adepth of 3 feet . arae e f We - SEPTIC TANK. r ❑ Type/Mfg PKG. TREATMENT PLS: 0.% r f l Distance to;nearest: � LQACHING LINE 0 No. & Length of lines FILTER BED I Ci Distance to nearest: "Capacity No. Companmants Method of Disposal l__ $Well �c Foundation/ —Property Line. Well !'' - ' Totat length __ `�� Y:�Pro ert Foundation P Y Line i 1i V - j Number �-- ! SEEPAGE PITS f� 11Y Depth Site a Cl.' Distance to nearest: Well . r�/_ Foundation l Property Line -• r SUMPS 1: " ' DISPOSAL PONDS ' ❑ I hereby certify that l have prepared this application and that the work will be done in accordance with San JriagUin county ordinances, state laws, and I rules and regulations of the San Joaquin County l Home ov3ner or licensed agent's signature certifies the "i certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner. as to become subject to,workman's compensation laws of California." Contractor's hiripg or sub contracting s'igna'ture employ any person i in u certify that in the performance of the work for which this permit is issued, I shiti employ persons subject to workman's compensa- tion laws of California." t P/ -y/ .j/' �j�� The appli ant all re lulr ; 4 spa s. C / lets drawing 'on reverse side. --- r Date: Signed .......... _--__T_ F AOR PArATMENT USE ONLY '} � d Date � �...._ Area Application Accepted by __ _� Pit or Grout Inspection by Additional Comments: Applicant - Return aiL copies to . EH 13-24 iFIEV- t i n 5 Data _ Final Inspection by San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 —] Date L