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F SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �R ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 I P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made:ito 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. Job Address,1--�p� Cit Lot Size/Acreage Owner's Name�/ S I� Address / Phone / Contractor L& Address ` � License No. Phone TYPE OF WELL/PUMP: i! NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR C1OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial O Open Bottom © Manteca Dia. of Well Excavation Dia. of Welt Casing til Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Cl Public 1-1 Other 1-1 Delta Depth of Grout Seal Type of Grout G I I Irrigation _.Approx, Depth l I Eastern Surface Seat installed by r Repair Work Done 12 Type of Pump H.P, State Work Done v Well Destruction ❑ well Diameter Sealing Material & Depth Depths Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ! DESTRUCTION o septic system permitted if public sewer is ,ill, available within 200 feet.l Installation will serve: Residence Commercial_ Other Number of living units: I` Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity - No. Compartments i PKG. TREATMENT PLT. ❑ i� Method of Disposal Distance to nearest: Well Foundation Property Line IM LEACHING LINE C1 No. & Length of tines Total length/size I FILTER BED ❑ Distance to nearest. Well Foundation Property Line IM } SEEPAGE PITS it Depth Size Number ,I _ SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 11 . 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 parson 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 taws of California." iM The applicant must call for all required insPections.Complete drawing on reverse side. Signed ` Title: Date: 7 R DEPARTMENT USE ONLY Application Accepted by Date 9 2 Area ' OAO Pit or Grout inspection by II Date Final Inspection b Date Additional Comments: I� ii Applicant - Return all copies to: San Joaquin County Public Health Services , I` Environmental Health Permit/Services ` I .445-N San. Joaquin, P O Boif'2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. INFO CASH �jf �j . EK11-24irtEV.IinSi III �� ® � sl (/ Z EH t4a6