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SAN .,,._.QUIN COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL HEALTH DIVISIOlY 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 Service p Job Address -7/f r' / ��` �l-�� eci-.- City Lot Size/Acreage Owner's Name Z/m S" Address Phone Contractor i►t. Address _ nse No. Phone TYPE OF WELL/PUMP. N W WELL WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well O PUMP INSTAL LA N SYST REPAIR OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK EWER LINESDISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC IaIJS iy Cl In trial pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack L Tracy Type of Casing___ Specifications i'�l Public 1 1 Other n Delta Depth of Grout Seal Ty e of Grout �ipation Approx. Oe 11 Eastern S}rrface Seal Installed by �'Jrfi _ Repair Work Done Ll Type of Pump -e•�"_`4 H.P, ! State Work Done _ Well Destruction ❑ Well Diameter r Sealing Milli i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I [No septic system permitted if public se er is O available within 200 feet.) Installa -s t . Residence_ Commercial_ Other Number of living units:�mber-o f bedrooms Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O ��_ Method of Disposal Distance to nearest: Well Foundation __-Property Line LEACHING LINE L1 No. & Length of lines Total length/size FILTER BED (7) Distance to nearest: Well Foundation Property Line SEEPAGE PITS 1i Depth Size Number _ SUMPS t.l 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 following: "I certify tji..dtrh,,a performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica t t all for all re ctions. Complete drawing on re4 1 side. Signed X ` ' 9 Title: � Date: SRF DEPARTMENT USE ONLY Application Accepted by DateArea d^/L Pit or G�o Inspection by Date - Final Inspection by-��= Date Additional Comments: IN Applicant - Return all copies to: San Joaquin County Public ealth ServicesV�rt3.1M/� ^� Environmental Health Perm t/Services 445 N San Joaquin,_�O B x 2009, Stkn, CA 95201 I FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED By AT P RMIT'NO. EH 13.2 IREV,f i x 51 +"NFO' EH tt-20 . 1�