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SAN _iQUIN COUNTY PUBLIC HEALTH . :VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 y �p 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 /Services. Job Address 42 V03 /Y�i�fJ {'/IJI�J Cays'll"MSize/Acreage � — TernwhN Owner's NameAddress Phone Comractoly—an —Ta Addres� R©13Ok Gla— License ST I No) 3 Phone TYPE OF WELL/PUMP. NEVV WELL ❑ WELL REPLACEMENT DESTRUCTION Vout of Service Weil ❑ 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 USE, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS G Industrial O Open Bottom ❑ Manteca Die. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications .'i Public F1 Other Delta Depth of Grout Seal Trpe of Grout 11 ligation _ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Worr Done _ Well Destruction *0�Well Diameter Sealing Material i Depth Depth Filler Material i Depth w ` Is TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I (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/Mfg T Ca rty Ho. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: II undation Properttf Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth S a Number SUMPS LI Distance to nearest: ell Foundatio Property Line DISPOSAL PONOS ❑ I hereby cenify 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 regula o en Joaquin County Home owner licensed agen signature certifies the following: "I certify that in the performance of the work for which this permit is issued. I shall not employ any rson in such ma ner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies t following: "I conif that in the rform, a the work for which this permit is issued, I shall employ persons subject to workman'a compensa- tion law of Cslifor ia." The ap icant all req red omp to drawing o rse s Signed X � '�� Date: 92- ryFnn DEPARTMENT USE ONLY —)Yl / J� T Application Accepted by _ ,/ 'n� /J�� Date _ / Area . .Uo Zhrgcq Pit or Grout Inspection by �o Date _ F,iinalal Inspection by `�' Dat4> �IV61 Additional Comments: 1 peVfDrQ�Z (Y�1 IDD^3rJ g2f55UYC �' I GtJ{' Q}FC WCi Lp �(/1/1l/�Vlt . � 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 INFO AMOUNT DUE AMOUNT REMITTED CA/SH RECEIVED BY DATE yn EH EH 4.26 vv