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'4- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (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. F, Job Address qt)q2 4A City Lot: Size/Acreage h Owner's Name Address # Phone Contractor Address License Nc �. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n 4 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ i STEM REPAIR 11 OTHER ❑ Monitoring Well F DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE - T.. -FOUNDATION ,AGRICULTURE - OTHER WELLPIT5/Sl1MP5_ INTENDED USE -'TYPE OF 1NEL`L PROBLEM AREA," STRUCTION SPECIFICATIONS- O ❑ Industrial ❑ Open Bottom ❑ Manteca �. Dia. of Well Excavation Dia. of Well Casing Ca Domestic/Private Gl Gravel Pack ❑ Tracy Typ of Casing_ Specifications FI Public f-1 Other fl Delta Dep of Grout Seal Type of Grout ` I I Irrigation '. Approx. Depth I I Eastern Surf ce Seal Installed by rw\ Repair Work Done ❑ Type of Pump H"P. - State Work Done _ Weil Destruction ❑ Well Diameter Sealing Material E Depth Depth Filler Material b Depth r r TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I D TRUCTION I I INo septic system permitted it public sewer is ' Zble withi 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms !` Character of soil to a depth of 3 feet: h SEPTIC TANK ❑ Type/Mfg Capacity Aompartmer IPKG. TREATMENT PLT. ❑ sal Distance'to nearest: Well Foundation P LEACHING LINE Cl No. & Length of fines Tal FILTER BED k ❑ Distance to nearest: Well Foundation Pro y Line (\ SEEPAGE PITS' 11 Depth Size Number µ SUMPS Li Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ ' i I 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 iignature 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 applican ust call fo required ' spections. Complete drawing on reverse side.._ Signed Xil Title: Date: T FOIL DEPARTMENT USE ONLY Applica ' n Accepted by cz Date JQ Area -�-1- --- Pit or Grout Inspection by Data Final Inspection by J Date--1121-125J-01 Additional Comment$: d 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 rFEE I AMOUNT DUE AMOU7 REMITTED K RECEIVED 8Y DATE PERMIT'N0. INFO /j . EH 13-24(REV.i i n sl Lf,. 7,D 14.26 f{ i �/ VVV