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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 (COP 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 bis Health Services. Job Address �7 3 -3 A) `^ City Lot Size/Acreage V T)fOwner's Name r✓�� l/JL (Address Phone Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications I•I Public t_1 Other 1711 Delta Depth of Grout Seal Type of Grout I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by it Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth fi Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 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: i Water table depth SEPTIC TANK O Type/Mfg 1 ? Capacity f) No. Compartments PKG. TREATMENT PLT. ❑ Method ofD'spos I 1' Distance to nearelt:'? <<W811 Foundation Property Line �(-s1 } LEACHING LINE Ll No. 6 Length of lines Total length/size I FILTER BED C)- Distance to clearest: We11 'Foundation Property Line —+- SEEPAGE PITS I I`Depth Size Number i; SUMPS LI Distance to nearest: Well , Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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 Jbaquiri County ' Home bwner 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 nod 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 that in the performance of the work'tor which this pAtmit.is issued, I shall imploy personi subject to workman's compenss- ytion laws of California." The applicant must call for all required inspections. Complbl8 drawing ort reverse) side. Signed X Title: Date: R DEPARTMENT USE ONLY Application Accepted by r bate Area yi a Pit or Grout Inspection ate Final Inspection t`y Date t Additional Comments: Applicant Return all copies to: Stn Joaquin County Public Health Services Environmental Health Permit/Services .y 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT Dt1E AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. / }> ^i EH1324IREV.rinse � t EH 1426 t �?