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SAN( iAQUIN COUNTY PUBLIC HEALTH3RVICES 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. Job Address City Lot Sine/Acreage � � Phone Owner's Name Address Contractor 11 Address V License No. �` Phone— TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLA EMENT _ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR El OTHER O Monitoring Well C7 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 L1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation — Dia. of Well Casing [} DomesticlPrivate 0 Gravel Pack ❑ Tracy Type of Casing. Specifications I'1 Public I-1 Other Cl Delta Depth of Grout Seal Type of Grout I i Irrigation —Approx. Depth l I Eastern Surface Seat Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTIONINo septic system permitted if public sewer is �J available within 200 feet,) Installation will serve: Residence— Commercial Other Number of living units: u e oa Character of sol)to a de hof 3 Water table depth _ 4• SEPTIC TANK- ❑ T /Mf, - ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Type/Mf may ave exp) l Method of Disposal VM*cb@i1�gpMp1��d �-� �t3� � It:,lion Property Line 1 t' LEACHING LINE ❑ & Len W1 lnes'� Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line _ SEEPAGE PITS 11 Depth w^ Size Number 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 th oaquin County Home owner or Ei agent's i lure certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any per n in such nner as become subject to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the f rtify that t performance of the work for which this permit is issued, I shall employ persona subject to workman's cc pensa tion lewa o alifornia." The eppli nt�1,tcalilrreq red inspections. Gorr late drawing on r e side�.,� y Signed X Title: ""�'r "� Date: FOR DEPARTMENT USE ONLY Application Accepted by Dater `t rZ Area Pit or Grout inspection by Date Final Inspection by - _ _-- Date Addilii Qalq menta: }� _ �! r A�plicaht - Re uz'In a fAes V'JPan oaqu n�Coun y P1fb1 c Heal-flIti�Services 5l� �� Jam+ i �!'1�/ i1►,t Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 9520111 r�% 14. FEE AMOUNT DUE AMOUNT REMITTED I LASH RECEIVED BY DATE PERMIT'NO. g�014 INFO . EH 13.26(REV.t Si lJ t:H l4•2a '7q