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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1 445 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. Q s� City lr &1 - Lot Size/Acreage Owner'a Ne �� ► f lr Address 1 t 0'7� J' ' df? '�' Phone q 3I`o 7 Contractor S t- P Address License No. Phone TYPE OF WELL/PUMP, NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E- Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Ck Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing___.. Specifications 1'} Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation ____ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADDITION I DESTRUCTION J 1No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence'"_ Commercial— Other Number of living units: _Z.�-_ Number of bedrooms <� r Character of soil to a depth of 3 feet: L Water table depth SEPTIC TANK IZ1--Type/Mfg7Ti L Gr eTrCapacity Il 4 d`(S No. Compartments PKG. TREATMENT PLT. ❑ % . Method of Disp9sal Distance to nearest: Well d fi- Foundation I Property Line 5 a LEACHING LINE EI7No. & Length of lines C{ Total length/size 2 Cr f FILTER BED F) Distance to nearest: Well _ Foundation O Property Line SEEPAGE PITS I I Depth Size_ Nrmber SUMPS Cr Distance to nearest: Well ^ Foundation�Q_ Property Line DISPOSAL PONDS ❑ - to Z g r 7 - 7-0 X r I hereby certify that I have prepared this application and that the work wilt 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, t 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: 1 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 must call for all required inspections. Complete drawing on reverse side. Signed - Title; _ Date: R DEP7M SE ONLY Application Accepted by 7 p� - __r..� Dal Area Pit or Grout Inspection by Da a Final Inspection Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO CASH A p f EH 1 4-2e(REV.riKs�Ze O d yyz K �7 ��