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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION r 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 t k PERMIT EgPIRES 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 Pub le Heald services. !VD ��/1 City Lot Size/Acreage Job Address - Phone V Owner's Name 04 oD2�lVkc3r1`S" `� 4 �3 Z icense No. Phone ontractor WELL REPLACEMEN 7 DESTRUCTION ❑ Out of Service Well C1 TYPE OF WELLIPUMP.: I� NEW W ❑ OTHER O Monitoring Well C7 , PUM ' INSTALLATION SYSTEM REPAIR L] DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �Xt,• "' INTENDED USE TYA OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Weil Casing w` nIn trial ❑ Op;n Bottom a Manteca Dia. of Well Excavation Specifications• #- k Domestic/Private ❑ Gravel Pack L] Tracy Type of Casing_ ti. �l Delta Depth of Grout Seal Type t Grout I'1 Public 1. f:7 Ot4 r I I litigation Approx. Depth I i Eastern Surface Seal Installed by ., FH.P. State Work Done Repair Work Done U Type of Pump Sealing Material & Depth Well Destruction ! ❑ Well Diameter k Depth F � Filler Material & Depth • , - 3system permitted TYPE OF SEPTIC WORK: NE INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTION I I atvailabetr .)within 200 feetif public sewer is S Installation will serve: Residence Commercial Other 4.Number of living units: Number of bedrooms ., Water table depth Character of soil to a depth of 3 feet: SEPTIC TANK. ❑ Type/Mfg Capacity No...Compartments, r f PKG. TREATMENT PLT. Cl r I� - �- _� Method of Disposal r F Property Line Distance to nearest:; Well FoundatiomY I "��' :-- ;Total length/size LEACHING LINE ❑ No. 8 Length of'lir�ris FILTER BED ❑ Distance to nearest - Well 4 Foundation~ `""J Property Line -�t �.. ..,.-... . ._:. . .�. ..r- :. Number SEEPAGE PITS t 11 Depth Size SUMPS Ll Distance to neares't'. Well f Foundation} _ ___ Property Line DISPOSAL PONDS° ❑ �� { tip '� e,c.i+ I hereby certify that I have prepared this applicatjon and that the work Will be.doneiin 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 shalt not employ any person in such manner as to become stjbject�to workrrian's compensation"Sawa ril'California." Contractor's hiring or sub contracting signature certifies the following: "I certify'that in the performance of the work for whidh this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." II� q r The applican st ll Hl required insppctions. Complete drawing on revitf1pe side. n� Signed Title: Data: _ T USE ONLY } Application Acceptad by Date � L• Ara I III ' Date Final Inspection by Date Pit or Grout Inspection by +.. Additional Comments: i Applicant - Return all copies to: San Joaquin County Public Health Services ` Environmental Health Permit/Services I, 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMO DtaE VTED CK RECEIVED By DATE PERMIT"N0. r INFOI! q . EH 17.21 1REV.1/N 51 I EH t1-a6 F, _..