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r APPLICATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 4 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) fplication is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This plication Is made in compliance vith San Joaquin County Ordinance No. 544 and 1862 and the Rules end Regulations of San Joaquin County Public Health Services. Job Address _ C30 � ---T— .� City Lot size/Acreage Owner's Name Address G Phone LLQ- T - Contractor_ ��}-��Address "License No. SM Phone TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED__US"E-, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl Industrial; ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing— I') Public (-I Other 171 Delta' Depth of Grout Seal Type of Grout I I frrigatian �.App(ox, Depth 11 Eastern Surface teal Installed by 1J, Repair Work;Done LJ Type of Pump ' "H.P. State Work Done Well Destruction 'Cl Well Diameter Sealing Material & Depth i Depth Fi31er Mnteriel & Depth Q) TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRf DDITfON 1 I DESTRUCTION I i (No septic system permitted if public sewer is available within 200 feet.i Instalfatiori will serve: Residence-Y-- Cominercral .�Cher Number of living units: _ Number of be rooms Character bf soil to a depth of 3,feet: ;`�eKa�,fD Water table depth "d SEPTIC TANK. Type/Mfg C tZ � Capacity PKG.KG. TREATMENT PLT.❑ ---�-�� No. Compartments t- Method of Dispos Distance to nearest: well -Foundation-� .Foundation Property Line LEACHING LINE No. & Length of lines O t Total length/size FILTER BED [7 Distance to nearest: Well ` Property Lina — _ Foundation SEEPAGE PITS Pl- Depth a- Size SUMPS Number 3 LI Distance to nearest: Well Foundation DISPOSAL PONDS ❑ Property Line tDf D5 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-car ify 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 applicant must II or all requi d in pections. Complete drawing on reverse side, Signed Tiffs: rl Date: F R EPARTMENT USE ONLY Application Accepted by Data T A a rea Or Grout Inspection by t 7r�' beta Final Inspection by Data « Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services /� l 445 N San Joaquin, P O Sox 2009, Stkn, GA 95201 A,? w FEE AMOUNT DUE ANOUN7 REMITTED T 1 INFO ASH RECEIVED BY DATE PERMIT'NO. « EM 13-241REV.+1 n sl