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/7z/eg SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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) i 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. V Job Address S t h A City S� k"Lot Size/Acreage Owner's NameY✓ � `� 1 !T Address 1 hone 3' Contractor_&22 Address O AJ k:lLIhicense No. Phone `-' 3' S�7I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well G7 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 M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing OO Aomesiic/Private ❑ Gravel Pack Ll Tracy Type of Casing_ Specifications I'] Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout I I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material & Depth Depth Filler Material. & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION INo septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence.,.Commercial,.,_.._, Other j Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. Type/Mfg Capacity 60 _ No. Companments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well S a Foundation d Property Line LEACHING LINE Lir No. & Length of lines Total length/size FILTER BED ID Distance to nearest: WeN 50 Foundation 7-.e.2 Property Line SEEPAGE PITS k Depth a Size 33 Number I l SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 1 certifies the following: "I certify that in the performanc,,�,".*in work for which this permit is issued, 1 shall employ persons subject to workman's compensa- tion laws of California." " -'f The applicant mus cal for 91L rmulred In 4te drawing on reverse side. Signed X_ _ rj itle: Date: Z— 1 � Fr ARTMENT USE ONLY j Application Accepted by Date �^ Area i r Pit or Grout Inspection by ate Final Inspection by Data day Additional Comments: Applicant - Return all copies, to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P D Box 2009, Stkn, CA 95201 J__3FEE � INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMI7'NO. . t:H 13.74 IAEV.,l n si 7� Ov h EH 14-M I