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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAY -:,y,• ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 itECkr '` P O BOX 2009, STOCKTON, CA 95201 APR 2 I� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN JOA(�r li PUBLIC H�4l, ) (Complete in Triplicate ,i ENVIRONMENTAL 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. 1_' k Job Address Tas �I t trlrtr :S VC4 City �`-� Lott Size/Acreage YJ1tN1�� r S1`>>WC S�C�1 Phone w Owner's Name Address �^y Contractors`^^ I� 1 Address 1e License No. Phone TYPE OF WELL/PUMP: ;i NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well L"1 _ PUMP INSTALLATION ❑ SYSTEM REPAIR D OTHER t.Ing Wel ❑ SCO SEWER LINES �S6 DISPOSAL FLD._ _ �QPROP. LINE r DISTANCE TO NEAREST: SEPTIC TANK - FOUNDATION t S AGRICULTURE WELL OTHER WELL PITS/SUMPStsd1, INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation �i _ Dia. of Well Casing FI Domestic/Private ❑ Grevel Pack7 ❑ Tracy Type of Casing_ Specifications I'I Public y Other $f Delta Depth of Grout Seal __0`7,6' Type of Grout ►�1 � f 11 Irrigation . 7-0 :Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Weil Destruction ❑ Well Diameter Sealing Material & Depth Isar ` w Depth -s ZO6 Filler Material & Depth �1 C TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is 1 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/M19 Capacity No. Compartments PKG. TREATMENT PLT. ❑ I Method of Disposal Distance to nearest: Well foundation Property Line LEACHING LINE D Ni". & Length of lines Total length/size FILTER BED ❑ D-tstance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number L SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C3 h'. yy -tom - 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 Sari`Joaquin County t 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 subcontracting 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 applicanst call t all r quired inspections. Complete drawing on reverse side. Signed r Title: s T Date: yq FOR DE ARTMENT USE ONLY - Application Accepted by �- Date p (� Area Pit or Grout Inspection bynom+ Date f12I �� Final Inspection by ` ___ Date S y j Additional Comments: "7 Applicant - Return all copies o: San Joaquin County Public Health Services h 900 ST Environmental Health Permit/Services ` 0. 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE. AMOUNT REMITTED I CK RECEIVED BY DATE PERMIT N0. INFO (� CASH . EH 13.24 iREV.tiKsl X 6 1-0737 JH 14-25 C.J