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-A 74V SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN,- PHONE (209)468-3420 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 3 f � V 4A- City of Size/Acreage Job Address Owner's Name �A � Address Phone 5 Conlracto is k r-+ Address r 2 License No.5 -Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN DESTRUCTION Dut or Service ring Well 0 F PUMP INSTALLATION C, SYSTEM REPAIR Cl OTHER G DISTANCE TO NEAREST: SEPTIC TANK ;..,]:� -- SEWER LINES -� DISPOSAL FLD. �� PROP. LINE FOUNDATION AGRICULTURE WELL THEIR WELL-.&- PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �i R Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation�// Dia. of Well Casing Domestic/Private Gravel Pack7 ❑ Tracy Type of Casing_. Specifications r of Grout V1 Public Ll Otiir�� fl Delta Depth of Grout Seal f� �]�r I I Irrigation Ap r x. Depth I 1 Eastern Surface Seal Installed by �S F� 1iL�r Repair Work Done 0 Type of Pump �_- H.P, State Work pone _ Sealing Well Destruction �` Well Diameter r Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION"I I DESTRUCTION I I iN3ptic thin system ermifle iiabd if public sewer is Installation will serve: Residence— Commercial .....T 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 L1 No. & Length of lines Total length/size FILTER BED n Distance to nearest: Weil Foundation Property Line I 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 foilowing: "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 m scall tof all require 'ns trctions. Complete drawing on reverse ode. I )(� «' — Title: �rGl ►n --- Date: Signed FOR EPARTMENT USE ONLY O °L Application Accepted by Date rea Pito G ou inspection by Data Final Inspection by Dete Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services I� 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY TE PERMIT NO. r INFO . EH 13.24 1REV.I I N 5) W EH 11-2s k - J