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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Country Public Health Services. Job Address;; `. ; City Lot Size/Acreage Owner's Name 16-4,,/ Address Phon.A�'7 22 Contractor�pZtZ--L9Addressf. (1t� /,&a /�-� License NoIG273 _Phone 2 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER 11 Monitoring Well L7 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F.] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing__ Specifications i'1 Public - 1-1 Other 171 Delta Depth of Grout Seal Type of Grout (� i I Irrigation _Approx. Depth Il Eastern Surface Seal Installed by \\tel Repair Work Done i4L Type of Pump H.P. 1- State Work Done Well Destruction ❑ Well Diameter Settling Material & Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 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: t Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No, Companments PKG. TREATMENT PLT. ❑ i Method of Disposal Distance to nearest: . Well Foundation Property Line r 4 LEACHING LIME ❑ No. & Length of lines Total length/size FILTER BED 0 Distance,to nearest: Well Foundation Property Line - - SEEPAGE PITS 11 Depth Size Number SUMPS LI 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, an 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 of California." The applicant m st call for afl r wired inspections. Complete drawing on reverse side. 7 Signed Titla: J/ Date: -] �� FOR DEPARTMENT USE ONLY Application Accepted by QaCAI.L Date 3^)--4-eL3_ Area Pit or Grout Inspection by Date Final Inspection by Date 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 AMOUNT DUE AMOUNT REMITTEDC K RECEIVED BY D E PERMIT ND. INFO. EH 13.24{AEV.FinSi �00 EH 14.26 ✓✓✓