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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 Publ7�c Health Services. Job Address �tr� Aead L__ City Lot Size/Acreage s r w er s Nam ddress Phone 4JI_�2a 7 /� r oror s +� 1 Z+�" L�,e e. Phone t ~� TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT . DESTRUCTION ❑ Out of Service Well In PUMP INSTALLATION M SYSTEM REPAIR 0 OTHER ❑ 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 171 Industrial O Open Bottom 0 Manteca Dia. of Well Excavation _ Dia. of Well Casing omestic/Private ❑ Gravel Pack ElTracy Type of Casing_ Specifications I'I Public El Other R Delta Depth of Grout Seal Type of Grout I I Irrigation _,Approx. Dept I 1 Eastern I urface Seai Installed by Repair Work Done L] Type of Pump H.P. _ State Work D Well Destruction O Well Diame er Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 1 DESTRUCTION l I (No 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 LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ a ;I 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, an had 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 rnanner 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 applic st call r a q iced ' speytions. Complete drawing on rev r side. q—? —q r?—q Signed f! Title: Date: — FOR DEPARTMENT USE ONLY Application Accepted by Date / Z Area -�77 Z��qq Pit or Grout Inspection by Date Final Inspection by Dated '2 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 CK 8 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. IN0 , +} G f . EH c324)REV.i/n5i 0Z` 0� t -l� r� ( 8 EH 14.25