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W 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address . Pdity Lot Size/Acreage a M�k Own r'S Name Address Meg Phone ac'f�� e s f v�V iCe se No. `��,�tlone �`��✓` TYPE OF WELL/PUMP: NEW WE WELL REPLACEME Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER d Monitoring Well 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 F) Industrial ❑ Open Bottom ❑ Manteca Ria. of Well Excavation Dia. of Well Casing estic/Private ❑ Gravel Pack C] Tracy Type of Casing_ Specifications 'I Public Cl Other F1 Delta Depth of Grout Seal Type of Grout I I Irrigation _,Approx. Depth I 1 Ea rn Surface Seal Installed by Repair Work Done 0 Type of Pump / H.P� State Work Done XW Well Destruction ❑ Well Diameter _CP g Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIWADDITION I I DESTRUCTION I I iNo septic system permitted it public sewer is available within 200 feet.) r, 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. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of h6es Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line r SEEPAGE PITS 41 I Depth � .Size """ Number SUMPS Ll Distance to nearest: Well Foundation 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 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 o C ' rni ." The app lic fiu t ca or uired ' spections. Complete drawing on re side. Si ne Title: Date: 71 FOR DEPARTMENT USE ONLYrr Application Accepted by Data ^�Z Area O k� Pit or Grout Inspection by Date Final Inspection by 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, CA 95201 FEE INFO AMOUNT DUE AMO NT REMITTED CK RECEIVED BY f 0 TE PERMIT'N/0.. j EH13.241REv.i/Hss '��0 �� •'1 / EH 1426 / I