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F �I t I� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I i ENVIRONMENTAL HEALTH DIVISION II 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I (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 Public Health Services. Address / �2 0"?, Job City of Size/Acreage �1 �i�-res Owner's Nam Address Phone Contractor _Address License No. Phone TYPE OF WELL/PUMP: NEW WELL C7 WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C1 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYk OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i. f--1 Industrial ❑ Open Bottom I1 Manteca Dia. of Well Excavation Dia. of Weil Casing .i C7 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications Cl Public 1-1 Other (-1 Delta Depth of Grout Seal Type of Grout I I I Irrigation _..Approx. Depth t I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work.-Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depths Filler Material & Depth : 1 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION (No septic system permitted if public sewer.is avaiiabie within 200 feet,) r Installation will serve: Residence __ "Commercial_ Other v� Number of living units: Number of Bedrooms Character of soil to a depth of,3 feet: t Water table depth ' ` SEPTIC TANK.. ❑ Type/Mfg Capacity No. Compartments ' L PKG. TREATMENT PLT, ❑ it Method of Disposal I i 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 IM SEEPAGE PITS I I Depth Size SUMPS LI Distance to nearest: Welt Foundation Property Line DISPOSAL PONDS ❑ IE "" `" V x C 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 thiat in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- tion law lifornia." lj 4 The licant m st call for all rsqui " ",ctions. Complete ing on reverse side. �-Z ^fined I" Title: —__ �{� � _ Date: OR DEPARTMENT USE ONLY Application Accepted bySS.ti�ti Date 5 Z Area Pit or Grout Inspection by lII Date Final inspection by Data Additional Comments: I! I 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 INFO AMOUNT.DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMIT NO. • EH 13 24 24IFIEV. EHkinsk � �� //++ i c0cdQ _Z . I� I