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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � l ENVIRONMENTAL HEALTH DIVISION ff 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 rade to San Joaquin County for a permit to construct and/or install the work herein described. This r application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San I Joaquin County Public Health Services. i P Job Address City Lot Size/Acreage - v f a Owner's Name �L,�-r_�x� � Address/, Phone '��t74 Contractor LnEAddress JC-110 License NA3323Phone TYPE OF WELL/PUMP: NEW WELL 12 -x WELL REPLACEMENT1� DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION.-g. , _ .` _'..;- SYSTEM.REPA)R ,0- OTHER-❑ Monitoring Well 0 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing IKDomestic/Private ❑ Gravel Pack ❑ Tracy Type;of Casing- Specifications I'3 Public I:1 Other ❑ Delta Depth of Grout Seal Type of Grout r r, I I Irrigation —.Approxi Dept t I Eastern a Surface Sedi installed by Repair Work Dons , Type of Pump H.P £ ` II— _ State Work Done Well Destruction ❑ Well Diameter Sealing Material Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION i I DESTRUCTION I I (No septic system p6rmitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_.,_,. Other Number of living units: Number of bedrooms k Character of soil to a depth of 3 feet: i Water table depth ` SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines t Total length/size FILTER BED ❑ Distance to nearest: Well Foundation �'w Property Line SEEPAGE PITS 11 Depth I Size Number SUMPS LI Distance to nearest: Well Foundation I 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 cavity that in the performance,of the work for which this permit is issued, I shall not i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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." !t The applicartul rust calf for all required ins ctions. Complete drawing on reverse side. 1 _/fir/ � Signed X Title: ^ ^ Date: .411 - � FOR DEPARTMENT USE ONLY Application Accepted by /p Date#' / / � 1�- Area Pit or Grout Inspection by Date Final Inspection by w . T Date Additional Comments.- Applicant omments: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 p IFEEO AMOUNT DUE AMOUNT REMiT,TED CASH RECEIVED BY DATE PERMIT'NNO'. F EM 124 1REV.i/r ai EH t4.42a