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f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES N b W �� ENVIRONMENTAL HEALTH DIVISION v 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 g be application is made in compliance With San Joaquin County Ordinance No. 549 and 1862 and the Rules and R�� of San Joaquin County Public Health Service's. Job Address — 11 lqy City St� fJLot Size/Acreage 41C/ 1Ol l J.6 Z77 Phone a� d Owner's Name �� Address / T - Address License No. Phone Contractor�— TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT P DESTRUCTION Cl Out of Service Well [D PUMP INSTALLATION El SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE 3 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ..� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i T.] Domestic/Private Ll Gravel Pack . ❑ Tracy Type of Casing_ Specifications ('1 Public CI Other r� 171 Delta Depth of Grout Seal Type of Grout I Irrigation —.Approx. Depth I i Eastern Surface Seal Installed by "� l Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction El Well Diameter' Sealing Material Depth Depth Filler Material & Depth TYPE OF SEPTIC-WORK: NEW INSTALLATION t I REPAIR/ADDITION.1 1 DESTRUCTION I (No septic system permitted if ptiblic sewer is available€ithin 200 feet.) Installation will serve: Residence _ Commercial Other . ^' Number of living units: Number of bedrooms ti ° Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK D Type/Mfg Capacity No. Compartments ! PKG.KG. TREATMENT PLT. Ll ' Method of..Disposal Distance to nearest:-?. Well` Foundation y `l� Property Line " fY I LEACHING LINE ❑ No. & Length of lines Total length/size ir FILTER BED ❑ Distance to nearest: Well Foundation Property Line------------------- SEEPAGE _,._.--___—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, 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-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 Californla." The applicant mut call for all required i spections. Complete drawing on reverse side. 2 f�tJ Title: ��' 10-e- - _ Date: fir'` `9-?- _ rgned X_ OR DEPARTMENT USE ONLY Application Accepted by 6�CA AMA f Date a Areal h4 Pit or Grout Inspection by Date Final Inspection by�' _ Date. : Y�` Additional Comments: Sr 1 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San-Joaquin, P D Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ASB I RECEIVED BY DATE PERMIT'NO. INFO ` , __ 9 �eq� . EH 13-241REV.r/asf . TIA c©�] r0 V t 1 4 1 Ali EH 14.20 5