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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-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. 54 and 1862 and the Rules and Regulations of San Joaquin County Public health Services. Job Address City Lot Size/Acreage tD�'"�`� Owner's Name c Address _ p-r-- Phone c� Contracior �"�"� S Address_ . License No. �U ©Y Phane `6/ -02. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REP CEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L) OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP-'LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i ❑ Industrial 0 Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack—L7 Tracy Type of Casing_ Specifications I'1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I Irrigation r _.Appiox. Depth I I Eastern y Surface Seal Installed by Repair Work Done L] Type of Pump H.P. State Work Done T y Well Destruction ❑ Well Diameter Y Sei aling l4aterial_.& Depth Depth r • Filler Material& Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR'/ADDITIO 1' DESTRUCTION l I (No septic system permitted it public sewer is !f �I 1 ' available within 200 feet.l Installation will serve: Residence!L�Comm,�er'ciel_ Other 4 y Number of living units: ,f Number of b-drooms ti %Character of soil to a depth of 31'feet: Water table depth s SEPTIC TANK. �' _Type/,Mfg Nom'- Capacity Z©® No. Compartments �- PKG. TREATMENT PLYT, CY' Method of Disposal r Y—Z Distance to nearest: Well . _ Foundation. al,LO Property Line 100 r LEACHING LINE" C1 No. & Length of lines G Total length/size FILTER BED C7 Distance to nearest::-'.Well 0. Foundation- .�� r Property Line k i �[ SEEPAGE PITS I I Depth Size _ Number � SUMPS LI Distance to nearest: Well Foundation _ o r Property Line�� , r 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, 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 i employ any person in such manner as to become-subject to workman's compensation laws of California." Contractor's hiring at sub-contracting signature I 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." � N, The applicant mu call o II requir ins tions. omplete drawing on reverse side. Signed X / Date: FOR DEPARTMENT USE ONLY Application Accepted by Z Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: r�� r�� r .+ e r21 41 i4. Applicant - Return all copies to: San Joaquin County Public Health Services 445EnvironmentalnJoa Health Permit/Services 445 N San Joaquin, P O Sox 2009, Stkn, CA 35201 FEE INFO AMOUNT DUE /AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. . EH1921(REV.i Y w Sl /� L EH 11.2E