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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) 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 Z 6 Job Address City Lot Size/Acreage Owner's Name Address Phone � 4 f 3Y-4 Contractor v f f�S S Address a t• ?a - _— License No 3� �F Phone TYPE OF WELL/PUMP: _ NEW WELL WELL REPLACEMENT ❑ DESTRUCTION`❑ Out of Service Well ❑ Monitoring Well PUMP INSTALLATION�16 SYSTEM REPAIR ❑ rte'°OTHER C3 C1 DISTANCE TO NEAREST: SEPTIC TANK /1Q SEWER LINES DISPOSAL FLD.f519 : PROP. LINEi2 FOUNDATION AGRICULTURE WELL OTHER WELL` PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " s Cl Industrial ❑ Open Bottom [3Manteca Dia. of Well Excavation Dia. of Well Casing ^� (eomestic/Private ;Gravel Pack ❑ Tracy Type of Casing— Specifications I'I Public Cl Other F1 Delta Depth of Grout al a� 4 T� f Grout_�- I i Irrigation 3 Approx, Depth [�i I I Eastern Surface Seal lnstalle `t Repair Work Done 0 Type of Pump H.P. Z"� State Work Dona Well Destruction Material & Depth Destruction ❑ Well Diameter � Depth Filler Material & Depth `¢ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION E I DESTRUCTION I I INo,septic sygem permitted if public sewer is available within 200 feet.) aI Installation will serve: Residence— Commercial— Other r Number of living units: Number of bedrooms , Character of soil to a depth of 3 feet: Water d&bfe depth SEPTIC TANK.. ❑ Type/Mfg CapacitNo. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal i Distance to nearest: Well Foundation Property Line t - LEACHING LINE 11 No. & Length of lines Total length/size—..- FILTER ength/size FILTER BED 1=I Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, l 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 certifies the following: "I certify this 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 f r all r uired inspections. Complete drawing on reverse side. q Signed Title: t. .x �• _ Data: OR DEPARTMENT USE ONLY i � � Application Accepted by Date x 1" 2 tea 0 ` Pit or Gfo+tx'Inspection by to Final Inspection by Date 0 r Additional Commenss: 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 �a f FEE AMOUNT DUE AMOYPT REMITTED CK RECEIVED BY DATE PERMITmNO. �T INF CASH I EH 13-21(REV.1/x51 t;H 162e ._