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' } 4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES r. 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 a.nd Regulations of San Joaquin County Public Health Services. Job Address — fl� LJ W"*"A*. 0. City �� Lot Size/Acreage r+ �� Phone 99f 1 �, Owner's Name G2'�"' C Address Contractor Address ia2 g License No Phone TYPE OF WELL/PUMP: NEW WELL C] WELL REPLACEMENT ❑ DESTRUCTION poqDut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing- Specifications 1'1 Public I-) Other n Delta Depth of Grout Sea[ Type of Grout ! I i Irrigation —.Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction Well Dia r j, T L/ Sealing Material & Depth" r' `�,� Pcz f d DepthFiller Material & Depth TYPE OF SEPTIC WORK-. NEW INSTALLATION I I-REPAIR/ADDITION 1 I DESTRUCTION 11ANo-septic system permitted.if public sewer is � available within 200 feet.i instillafion-will serk Residence'_-Commercial"=a0ther -- - -" Number of living units: Number of bedrooms ' Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, 0 Method of Disposal ` Distance to nearest: Well Foundation Property Line �] LEACHING LINE ❑ No. & Length of lines Total length/size . FILTER BED ❑ Distance to nearest: Wel[ Foundation - Property Line r � i 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, 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: "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." I The applicant all for all requiredin4 sect,ns. Co plate drawing o e se r y Signed Title: r_ Date: , i , 1 FOR DEPARTMENT USE ONLY ; Application Accepted by Date res 2� I Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services ! 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 i FEE AMOUNT 1111E AMOUNT REMITTED K INFO RECEIVED 8Y DATE PEflM1T'NO. . EH 17-24[AEV,r/Asl EH 1670