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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P 0 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 xith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Se vices. Job Address City Lot Size/Acreage Owner's NameA u2Address Phone Contrac rEms__ Address _7� License No.�� Z Z`� TYPE OF WELL/PUMP: NEW WELL C1 WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. UNE FOUNDATION AGRICULTURE WELL ' OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public M Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ DDITIONX DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence_ Commercial Other �= Number of living units: —/— Number of b ooms f Character of soil to a depth of 3 feet: Water table depth s' SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line f / LEACHING LINE No. & Length of lines -' © Total length/size FILTER BED ❑ Distance to nearest: Wall __ Foundation _ [� Property Line ^15- SEEPAGE SEEPAGE PITS Depth Sire Number X SUMPS Ll Distance to nearest: Well Q Foundations 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 prkma 's compensa- tion laws of California." The applica t call for W d inspections. Complete drawing on reverse si0,P Signed Title: • Date: `^ FO DEPARTMENT USE ONLY Application Accepted by Date :7-4Z r Area 2— p Pit or Grout Inspection by Date Final Inspection by Date 4 �- 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 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK 1 RECEIVED 8Y D TE �yPERMI9TlNNOO.q . EH 13-11(Rev.srls5) l 77 Z Z�""4TLJr EH 1416 ja, r