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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 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. r H Job Address L C+t '� Lot SizelAcreage Owner's Name Address `Ph"one r Contract ! & Address _ r License No. 74 7-2(P Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 13 Monitoring Well 0 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 r ❑ Industrial C1 Open Bottom El Manteca Pia. of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications I'l Public Cl Other fl Delta Depth of Grout Seal Type of Grout + I Irrigation Approrr, Depth t I Eastern Surface Seal installed by_ _ — Repair Work Done L7 Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material,& Depth TYPE OF SEPTIC WORK; NEW INSTALLATION REPAIR/ADDITION [ I\ DESTRUCTION I-I INo.septic'system permitted if public sewer is `/ available within 200 feet. Installation will-serve: Residence_� Commercial_ Other f Number of iiving,units: _/_ NuRmbBr of rooms Character of soil-to a dep of 3 feet:J r T Water table depth SEPTIC TANK' Type/Mfg- _ Capacity No. Compartments PKG. TREATMENT PLT.❑ ✓" ! Method of Disposal Distance to nearest: Well if Foundation' Property Line LEACHING LINE�- No:-& Length of lines To al length/size FILTER BED ❑ Distance to nearest: Well,�L�I Foundation _ ZO Property Line _ f - �! r SEEPAGE PITS Depth Size r � Number / SUMPS LI Distance to nearest: Well J Q Foundation 0 Property Line DISPOSAL PONDS ❑ I hereby certify that t have prepared this application and that the work will be done in accordance with San-Joaquin county ordinances,-s1ate..Iaws,-and?0_ - 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 notes 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 for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicantt call Tor al a ire inspections. Complete drawing on reverse side, Signed Title: \Zf P Date: FOR DEPARTMENT USE ONLY Ap icalion Accepted by �� Date �' �y,L Area Z Pi r Grout inspection by ate -r � Final Inspection by �! ,� Additional Comments: 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 FEE INFO AMOUNT DUE AMOUNT REMITTED SASH `RECEIVED BY DATE PERMIT'NO. EH EH 1t4-2a L� L +