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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)488-3420 IP O 'BO% 2009, STOCKTON, CA 95201 'PERMIT MIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) [ Application is hereby made to San Joaquin County for e permit to construct and/or install the work herei hed. is application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules an egulatio of Sa Joaquin County Public Heralthh Services. -�q Job Address/�7��V 11 r~i2,.��t22n _,,.,,_„�� City;,,��C.�LQ 1Rl Lot Size/Acr e [�c �tr��/ /n v�.e y R c� �f a -33o I Owner's Name ux dress Phone —Con - -Address-D. � , � --- _.. TYPE OF WELL/PUMP: NE WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Reil ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK ,Q,Q,&� SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPLS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation —T Dia. of Well Casin r Domestic/Private ❑ Gravel Pack C1 Tracy Type of Casing a Specifications ` i'1 iblic Cl Otrher Cl Delta,F, Depth of Grout Seal ' Type of Grout 4 !r Ualion 3a©Approx. aOt �stern Surface Sedl Installed by 1♦ Re it Work Done U Type of Pump '. H-P. tD State Work Done Weil Destruction ❑ Well Diameter Sealing Material & Depth ` Depth r 'Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIRIADDITION I 1 DESTRUCTION I 1 !No septic system per mitied�if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other j Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: f Water table depth ' SEPTIC TANK ❑ TypelMfg { 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/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth '1 Size Number �•/ � SUMPS Ll Distance to nearest: Well Foundation Property Line 1 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 I rules and regulations of the San Joaquin County I Home owner or licensed agent's signature cenifies 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 applicant st call for all requi d inspections. Complete drawing on reverse side. 4 Signi Data-: O/9 a- I g Title: Date: s i F MENT USE ONLY ` Application Accepted by Date �� ~s res Q Pi;or Grout Inspection by Date Final,Inspection by �tP t Dated o Additional Comments: Applicant - Return all copiesito: San Joaquin County Public Health Services Environmental Health Permit/Services• 445 N San Joaquin,,P O Box 2009, Stkti,, CA 95202 FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. EH 13-31[REV,iin01 EH 11.211 t �� &