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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) 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 CountyPublicHealth Services. A_ Job Address �/�� City �) Lot Size/Acreage _HF Owner's Name QL r AR" C-P'Q ��Address "107 Coda "Al !✓f _ Phone SAO^ 5 Contractor Q wli Address C.-A-0% �!`Q�Yr"i r�l License No. 1 /S�Z- Phone 7/ -16 TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT 1-1 DESTRUCTION O Out of Service Well Cl PUMP INSTALLATIO ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK r� SEWER LINES DISPOSAL FLO. -`_ 5100PROP. LINE VVin FOUNDATION =� AGRICULTURE WELL OTHER WELL ,- PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION, /r n Industrial pen Bottom O Manteca Dia. of Well Excavation I 5 Dia. of Well Casing �d Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ S=kas- Specifications `�G -- �� I'I Public Cl Other n Delta Depth of Grout Seal _ Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed bye---- v Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter .Sealing Material & Depth (� Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ O t� Number of living units: Number of b s Character of soil to a depth of 3fe Water table depth SEPTIC TANK ❑ T e/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distan on 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 followi : "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 Calif is. The applicant r a required ' pact! omplete Ing on reverse side. Signed X Title: � �` Date: F EPARTMENT USE ONLY *f Application Accepted by Date 30��Z AArea © , Pit or Grout Inspection by Ak Date---� !nal Inspection by< d9z ' Dat 406§Lt-,, Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services i 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CK 0 CASH RECEIVED BY DATE �PEERMIT'N0. 3.24 llJIY _u� 3�'1 7�/'1>00 EH 11.2a ` V �g 1 1p-" 1