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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION y 2 445 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 Services. Ipt) /�,. �# ,Ll- t7 N b� its W-4.0 _ City A Lot Size/Acreage Joh Address O � «� \t7 k Address S4/4 E Phone `rJ Owner's Name License No.�73fs Pihone33Y"Y)u Contractor �! i2aSf Address -- TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT .. DESTRUCTION ❑ out of Service Well ❑ ti Monitoring Well PUMP INSTALLATION f�ir OTHER ❑SYSTEM REPAIR 0 I DISTANCE TO NEAREST: SEPTIC TANK !22R-i" - SEWER LINES DISPOSAL FLD15 _ PROP. LINE Z FOUNOATION;-i AGRICULTURE WELL OTHER WELA.9 PITS/SUMPS q INTENDED USE. „y „y TYPE OF WELL PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS pia. of Cl Industrial ❑ Open Bottom El-Manteca, Dia. of Well Excavation_12 WellCasiri ' g Domestic/Private jgeGravel Pack ❑ Tracy �k Type of Casing_ o041-*'*Type i•1 Public 1-1 Other Cl Delta Depth of Grou'i'Seal ?� Type of Grout`' i I Irrigation 3 ZtZ..Approx. Depth l I Eastern Surface Seal Installed by _ Ce�''Ti�A A.- Repair Work Done U Type of Pump Z V H.P. -State Work Done,a s/!/ - p Sealing Material & Depth ` Well Destruction ❑ Well Diameter I i M Depth Filler Material & Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION i I INo septic system permitted it public sewer.is d available within 200 feet.I r Installation will serve: Residence_ _Commercial - Other .a Number of living units: Number of bedrooms Water table depth Character of sola to a depth of 3 feet: SEPTIC TANK. ❑ Type/Mfg Capacity Na Compartments PKG, TREATMENT PLT. El + Method of Disposal 1 Distance to nearest: Well " Foundation cPrgpeny Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well r Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line S 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 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- tton Iowa of California.' ,. The applicant mus call f9r all re uired inspections. Complete drawing on reverse side. Signed X �� -" _ Title: Date: 1 _ y FOR DEPARTMENT USE ONLY Application Accepted by Date Pit or37�rout Inspection by Data �on by Q Dat Additional Comments: qP Applicant - Return all cop to: San J aquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FE-E7- AMOUNT DUE AMOUNT REMIT7E0 CK 8 CASH RECEIVED BY DATE PERMIT'NO. INF I.,0 (EX + EM 13.24 1REV.r/N 5l I•, ty0 1 3 y' p p I EH 14.26 YX 17 y.�o