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SAN JOAQUIN COUNTY PU$LIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT ESPIRES 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 Pubbl]ic Health Sery Cgii � Joh Address I �H 0 W Y, _,I City Lot Size/Acreage Owner's Name Address Ganfte1 Phone MOW, Add�ss� 2 E �`•'Y� f tm.ense No. � to Phone 1 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n DESTRUCTION c Out of Service Well ❑ PUMP INSTALLATION ElSYSTEM REPAIR OTHER-.❑,.w.:.,. monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED=USE TYPEOF-WEC1 PROBLEMAREA—COt4STRUCTION-SPE-CIFtCATIONS^ ---- ❑ indust ial O Open Bottom ❑ Manteca Dia. of WeH Excavation Dia of Well Casing omesticlPrivate ❑ Gravel Pack Ll Tracy Type of Casing_ Specifications I"1 Public _ 1-1 Other 17 Delta Depth of Grout Seal Type of Grout I I Irrigation - Approx. Dept I I Eastern Surface Seat Installed by y _ Repair Work Done U Type of Pump H.P. y_I State Work Done Well Destruction - E) Well Diameter _ / Sealing Material & Depth to " Depth .rIf-P� + Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is t available within 200 feet.) \ Installation will serve: Residence_ Commercial— Other j Number of IM6j-units: Number of bedrooms h Character oftaoil-to s depth of 3 feet: F — ,Water table depth ,,,ASEPTIC TANK#, ❑ Type/Mfg Capacity No. Compartments + ,,PKG. TREATMENT PCT. ❑ Method of Disposal - '^ Distance to nearest: Well Foundation Property Line I i LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire -Number. SUMPS { Ll 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, 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 certifies the following: "1 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 applicMCustcall)f all required inspections. Complete drawing on averse side. Signed , � Title: XIA Date: FOR EP RTMENT USE ONLY Application Accepted by Date r 2__ Area i Pit or Grout Inspection by Date Final Inspection by Date,� _ r Additional Comments: Applicant - Return all copies to; San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 •FEE AMOUNT DUE AMOUNT REMITTEDCK CEIVED BY ATE PERM17'N0. INFO CASH 4DA EH 13.26 IREV.r/x 51 16010 EH tk.2e 777