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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 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 1862 and the Rules and Regulations of San Joaquin County Public Health Se ices. Job Address ✓' -' s` -t -'t_ City Z441— Lot Size/Acreage t Owner's Ns Address _ �� Phone r r Contract ddress P 6, box / i / ! License No` �Z � Z -Z Cp Phone 3csSLC TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT I , DESTRUCTION C. Out of Service Well Cl PUMP INSTALLATION C1 SYSTEM REPAIR C OTHER C Monitoring Well Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE n Industrial FI Domestic/ Private I'1 Public I I Irrigation Repair Work Done U Well Destruction ❑ TYPE OF WELL O Open Bottom Ll Gravel Pack CI Other — Approx. Depth Type of Pump Well Diameter J Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS CASHfr C1 Manteca Dia. of Well Excavation Dia. of Welt Casing 71 Tracy Type of Casing_ ._._.... ___. Specifications C Delta Depth of Grout Seal r Type of Grout l I Eastern Surface Saul Installed by H. P. State Work Done _ Sealing Material Z Depth __-fJ,1ler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION IEPAIRr DDITIO9<. DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Instaffation will serve: Ras' ence Commerciat ther Number of living units: Number of b rooms Character of soil to a depth of 3 feet: Water table.deDth _ SEPTIC TANK ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of -Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINENa. &Length o1 tines l ' (Total length/size--1 FILTER BED a O Distance to nearest: Well Foundation Q 4 Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state taws, and 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: "I cavity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion taws of California." The applica ust cal4 ell quired inspections. Complete drawing on reverse side Signed 1 Title: f; Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Area�`�_ Pit or Grout Inspection by Data Final Inspection by �Zd I Data _2_-_Zf�2- Additional -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, GA 95101 CK J EH 13-24 IREV. I/ n s EN t1 -m FEE AMOUNT DUE INFO AMOUNT REMITTED CASHfr RECEIVED NY DATE PERMINNO.