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z r 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Q� � Job Address v im' rb`"A City X&VJ r Lot Size/Acreage r Owner's Name Address/ Contractor �=J f j` AddresS4 S(G �_ •-reel _____ License Nql x��_ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Iwl Out of Service Well ❑ PUMP INSTALLATION Qe SYSTEM REPAIR C7 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL "OTHrR�GVELL 'NITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing IWDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ t Specifications I'! Public [I Other n Delta Depth of Grout Seal Type of Grout. I I Irrigation —.Approx. Dept I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. / _-__ State Work Done Well Destruction ❑ Well Diameter Sealing Material A Depth..--- ► a Depth Filler Material & Depth N TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION i I DESTRUCTION i I INo septic system permitted if public sewer is available within 200 feet.] Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line f t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cerlify 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 t 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." The applicant 9413Jst call for all required inspections. Complete drawing on reverse side. g c� Signed X _ T rifle: I Date: _ a f r Z FOP DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by A I I I ate q� q 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 IFEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. . EH 3.24(REV.1)K5111/11r EH 11.1e f