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SAN JOAQUIN COUNTY PUBLIC $EALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (?Ob)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 described. This application is trade in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 4 , Job Address —�� lit _ City Lot Sine/Acreage Owner's NameAddresse'[/L a Phone 4Cont+actor Address �/ ----P_ License No u Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR X' OTHER d Monitoring Well �7 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 11 Industrial ❑ Open Bottom ,t O.Manteca f Dia- of Well Excavation Dia. of Well Casing N )1 Domestic/Private ❑ Gravel Pack Y C7 Tracy Type of Casing_ Specifications ('I Public 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _..Approx. Depth l If astern Surface Seal Installed by , Repair Work Done >)r Type of Pump +S H.P, A State Work Don ��' Well Destruction © Well Diameter Sealing Material & Depth Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is 2 3 available within 200 feeit.1 Installation will serve: Residence Comrriercis[_ '.Other r Number of living units: Number,of bedrooms Character of soil to a depth of 3T feel: Water table depth SEPTIC TANK. ❑ Type/Mfg. f Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal y �, Distance to,nearest: Well • Foundation - Property Line I\� LEACHING LINE D No. a Length of lines ! Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation >'• Property Line SEEPAGE PITS I I Depth Size �'___ �Number SUMPS 0 Distance to nearest: Well Foundation r Property Line DISPOSAL PONDS ❑ 4 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 perlormance of the work for which this permit is issued;I shall employ persons subject to workmen'a ompensa- tion laws of Ca' " •' "' The scant must cal I or all required i tions. mplate drawing on re ide. /�} - e i Signed X Title: r �`�� Date: +�.�.� .... x.. OR DEPARTMENT USE b'NLY Application Accepted by Datet �� li ea Z Vit or Grout Inspection by Date Final Inspection by r� Date l a Z, , Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit ervices 445 N San Joaquin O o 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RE IVED BY DA PERMIT NO. INFO CASH . EH 172/IREV.iin5i , O�1 V i� fl EH 41-26 I 4