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t � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES -T,4 _-1 ENVIRONMENTAL HEALTH DIVISION t 445 N SAN JOAQUIN, PHONE (209)468-3420 D P O BOX 2009, STOCKTON, CA 95201 i ! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) . Application is hereby made to Scut 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. Job Address City Lot Size/Acreage Q �7/� Y �S f� rxi�r► A 953�honeZM Sq t� /�`f' Owner's Name �� r �— Address n �— �1 CA%vo t `�1� ,244-9 03 Contractor 1 k Address C License No. hone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT DESTRUCTION o Out of service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS .. _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION !/ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavat ion pia. of Well Casing C:] Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ Specifications I') Public 1-1 Other :Cl Delta Depth of Grout Seal ! �� - Type of Grout a- I I�Irrigation " 100!.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump H.P. State Work Done, Well Destruction ❑ Well Diameter Sealing Material b Depth Depth Filler Material Depth tll TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAMIADDITION l 1 DESTRUCTION i I INo septic system permitted if public sewer is available within 200 feet.) n ,� Installation will serve: Residence— Commercial Other 11 III Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: WatDO, rA� SEPTIC TANK ❑ Type/Mfg Capacity No. aay�8i ) PKG. TREATMENT PLT. ❑ Met � E Distance to nearest: Well Foundation Property L Q2 LEACHING LINE ❑ No. & Length of lines Total length r FILTER BED 0 Distance to nearest: Well Foundation IE1NVMfiW_Nater, DIVISION �. SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 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." The applicant must call for all r quired spa tions. Complete drawing on reverse i i ds. J �� Signed - Title: e. _ Date: / r _ 17 R DEPARTMENT USE ONLY Application Accepted by Date 2' Area Pit or Grout Inspection byDate Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services r 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 V EEk AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERM17'NO. FO EH 19.20 IRtV.t/M SYrm EH 14-20