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SAN J,. QUIN COUNTY PUBLIC HEALTH S,,..,17ICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT SIRES 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. 1 Job Address 0� (�I Ur V\j 1 se�I �A- I City Lot Size/Acreage Owner's Name Cocc, Cc, Et/1"t"c'Yn�ISCSAddress 1116'55 [A) I Uv S1,n t-t'L[AJRBhone Contractor MDQ Address SCS SC4 Al;0;11e_ 5.r- License No.� �Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT O DESTRUCTION XOut of Service Well ❑ PUMP INSTALLATION C 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 u Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing %1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public (.1 Other fl Delta Depth of Grout Seal Type of Grout 11 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump f-1orvc. H.P. State Work Done_ Well Destruction � Well Diameter R it Sealing Material & Depth ()n K re w v-� Depth $9.30 r Filler Material & Depth uyn.V-^ow+n TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is Q 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 Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line a LEACHING LINE O No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 taws of California." Contractor's hiring or sub-contracting 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." The applicant must call for all required inspections. Complete drawing on reverse side. Signed Title: �" 'c c,�" Vl`� i 11�� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date i Pit or Grout Inspection by Data Final Inspection by Dat Additional Comments: �^ Applicant - Return all copies to: San Joaquin County Public Health Services �C s 44Otel Health Permit/Services 5 NSan 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE /yP`E�RMIT NO. EM 3-24(REV. i n S� "+—� �" / S� {'�� ® EH 74.20