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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ' 445 N SAN JOAQUIN, PHONE (209)468--3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED p + Cpm lete in Triplicate) ( p p ) 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 eompliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address City CLot Size/Acreage Owner's Name Address 7_,-- Phone Contractar�// � - �/ls .__AddresZ�A�L License t�l/CJ �Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER C7 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial 0 Open Bottom C] Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications I'I Public (1 Other ❑ Delta [depth of Grout Seal Type of Grout I I Irritation —.Approx. Depth I I Eastern Surface Seal Installed by r` Repair Work Done Type of Pump. S6.9:=. H.P., 2� State Work Donee Well Destruction ❑ Well Diameter Sealing Material & Depth r Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if 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 © Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well. Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/sire FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONOS 0 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 California." The applic must cat or all required ins ions. Complete drawing on re era 'de. Signed X Title: Date: FOp• ,EPARTMENT USE ONLY Application Accepted by �C�_ +�-.OI'PILJV+h/1_ Date L Area Pit or Grout Inspection by Date Final Inspection b Datef Additional Comments: Applicant - Return all copies to: San Joaqu3n� County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, O Box 009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DAYE PERMIT•NO. . EH13-211REV.t!w 5VDL I H t426 T