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SAN AQUIN COUNTY PUBLIC HEALTH ;RVICES _._ ENVIRONMENTAL HEALTH DIVIS.-wA 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 Sar. Joaquin County Public Health Services. (� Job Address d � f� U'i 11A C, �j �k, Lot Size/Acreage C� / q ( wner's Name U,` /��f'S C/�H Address 'af 9 Z .Sc,7�xj AUC (' Phone 6 Z - Contractor mtLs _0Ok1T Address /fO QoAr 22 y4- 4CWL License No. 7895 9 Phone _ -90 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well [7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ S� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications I"I Public Cl Other n Delta Depth of Grout Seal _ Type of (shout " 1 I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth 'Filler Material &-Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public-sewer is available within 200 feet.) ' Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth / SEPTIC TANK ❑ Type/M ap ciNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal �t. near vNlj�Wuu�nlDistance 1 E-L Property LinePprm4t mclw have expired without t P Y LEACHING LINE ❑ No. 8 Len thh o lipes. �y �nenp Total length/size FILTER BED C) Distance t�f+a'a �t`e1ngApMp e e juli ppc ed Property Line -by "Viro=� -2I He_alth SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 p9rmit is issyod, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiiing or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman,'s compensa tion laws of California." The applicantmustcall for all required inspections. Complete drawing on reverse side. r Signed X /u � ,� Title: fees. Urso/ Date: FOR DEPARTMENT USE ONLY Application Accepted by - Date ' I A+ \ Area O l ' Pit or Grout Inspection by Date Final Inspection by Date 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 • EH 19-25IREV.rinse / Lf _0V rC C EH 14-25 `,