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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) i Application is hereby made to San Joaquin Count fors q y permit to construct and/or install the vork herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I 4 Job Address V City -5Lot Size/Acreage , �Ce�St o�VCxrrp Ca rcG �-}- rn'r Owner's Name rcrtelddress ,CIL ei ' Phone � I' lContraclar Address icr& DL k rd No. Phone !•-55e ' TYPE OF WELL/PUMP: NEW ELL © WELU REPLACEMENT E7-' —-DESTRUCTION ❑ Out of Service-Well- ❑- _ PUMP INSTALLATION ❑ ..SYSTEM REPAIR ❑ OTHER p Monitoring Well' IDISTANCE.10.NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/-5bW0t-____ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i n industrial p Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing II IEl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I V I Public' "' "fes"'C7 Other'" 11 Delta Depth of Grout Seal Type of Grout ii I Irrigation _Approx..Depth I 1 Eastern Surface Seal Installed by I �Repeir Work Done U Type of Pump r H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth r x f A-.- .Depth Filler Material 5 Depth � :TYPE OF SEPTIC WORK: NEW INSTALLATION_I I REPAIR/ADDITION i I DESTRUCTION o septic system permitted if public sewer is - - available within 200 feet.) installation will serve: Residence Commercial Other t [� f Number of living-units: "Number of bedrooms "^ t Character of soil to a depth of 3 feet: Water table depth = SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments .PKG 1 TREATMENT PLT. Cl - } Method of Disposal �t I i _ Distance to nearest: Well Foundation Property Line f LEACHING.LINE ❑ No. & Length of lines r 1 9 ` `:Total length/size f :FILTER 6ED 0 Distance to nearest: Well Foundation 1 Property Line SEEPAGE PITS 11 Depth -Size "`T f Number SUMPS Ll Distance to nearest Well Foundation Fro * .. party 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 aulesand 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, 1 shall not employ any parson in such manner as.to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature J -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 i tion laws of California," The appli t must call for all requi inspect' na to drawing o verse side. . g�9 Signe Title- _ Date: }` FOR DEPARTMENT USE ONLY + Application Accepted by Date " Area Pit or.Grout Inspection by T Date Final Inspection by Dots G Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services f 445 N-San_Joaquin, P 0 Box.,2009,-_Stkn,_CA,-95201.__,_•.,,-_FEE , AMOUNT DUE AMOUN REMITTED i INFO sy/may AS ECEIVED BY 0 TE PERMIT'NO. Eli 11.25