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SAN J' __QUIN COUNTY PUBLIC HEALTH 5h—VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-2420 P O BOX 2009 , STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F, (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 1852 and the Rules and Regulations of San Joaquin County Public Health Services. I job Address = �' City/ �L' Lot Size/Acreage .� I � f c `b Owner's Name- � -"4 Address =4!l�' _ Phone — —� ContractorAddress �v License flo.1_2'Y' Phone I TYPE OF WELL/PUMP: NEW WELL [ WELL REPLACEMENT ., DESTRUCTION D Out of Service Stell Cl PUMP INSTALLATION ❑ SYSTEM REPAIR L1 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L7 Industrial ❑ Open Bottom C] Manteca Dia. of Well Excavation Dia. of,Well Casing f:? Domestic/Private ❑ Gravel Pack L7 Tracy Type of Casing_ W Specificalions.� s I'1 Public 1-1 Other ❑ Delta Depth of Grout Seal Typo of Graut— I 1 Irrigation �.Approx. Depth I I Eastern Surface Seal installed by _ Repair Work Done L] Type of Pump H.P. State Work Done Well Destruction ❑ Wail Diameter Sealing Material & Depth i DepthFiller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION IV REPAIRIADDITION I I OESTRUCTION 1 1 ;No septic system permitted if public sewer is y Illi available within 200 feet.) installation will serve: ResidenceT Commercial Other I Number of living units: _�___ Number of bedrooms _ ' Character of soil to a depth of 3 lest: Water table depth SEPTIC TANK ❑ Type/Mfg. _- , Capacity No. Companmsnte PKG. TREATMENT PLT. ❑ /yMethod of Disposal Distance to nearest: We 1I foundation _ Property Line 4 LEACHING LINE ❑ No. & Length of lines Total length/size t FILTER BED 171 Distance to nearest: Well dt` ' Foundation C Property Line ATC FSEEPAGE PITS 11 Depth Sixe Number - SUMPS LI Distance to nearest: Well 4 Foundation Property Line DISPOSAL PONDS q 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 r 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 f employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature c" 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." 9 The applicant must call for all required inspections. Complete drawing on reverse side. / Signed X= � d ��z ra, _� 4 Title: ?1 Date: ! F R_DEPARTMEINT USE ONLY r Application Accepted byAe _ ,� t��f Date � � i E"-_ Area or Grout Inspection b s� �/ Gate��`�. r Final Inspection by �..C_ � Date�� !!Pz, Additional Comments: i. 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 AMOVNT pUE AMOUNT REMfTTED CKRECEIVED BY INFO CASH DATE ERfvtf': NG. ! 7,4 Cr