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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 Public Health Services. p1r Yjob Address r -L Ct+. �CiTy Lot Size/Acreage Owner's Name Address Phone b Xontfactor ©rrlt rw>« -'-_-._--Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 71 DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION RICULTURE WELL OTHER WELL ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE CONST CTION SPECIFICATIONS * Industrial ❑ Open Bottom ❑ Manteca f Well Excavation Dia. of Well Casing * Domestic/Private ❑ Gravel Pack 0 Tracy pe o ing_ Specifications Ul Public CI Other Cl Delta Depth of Grou al Type of Grout ` I I Irrigation _Approit. Depth ti Eastern Surface Soul Installed t�-/t11e Repair Work Done U Type of Pump P. State Wo na T l t Well Destruction ❑ Well Diameter Sealing Material & Depth �J�f Depth Filler Material & Depth TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTIOI (No septic system permitted it 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 D 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 El 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-contradting 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 must call for all required i spections. Complete drawing on reverse side. Signed XC.C- Title: �L'A-E pia-, Date: C? F DE RTMENT USE ONLY Application Accepted by kkA Date a rea Pit or Grout Inspection by Date Final Inspe tion by Date f 4.- Additional Comments: Applicant - Return ll copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO � CASH ( . EH 13-25IREV.r/n6 -7 Yt c-0D J' — y tV / EH i{-2a /