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-�- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON, CA 95201 WELL No. 7 <br /> PERbdIT EgPIRE 1 YEAR FRO D TE ISSUID <br /> (Complete in Triplicate) <br /> is <br /> Regulations of San <br /> Application is hereby made,"�SacAe V�hu1ancountyjura County ordinance r a permit to uNo. 549aand o1862sand thtall e Rules andwork eRegulationin ed. n <br /> application is made in ccepli <br /> Joaquin County Public Health Services. Lot Size/Acreage <br /> 942 S. Stockton Avenue city R�� °n`— <br /> Job Address 942 S. Stockton Ave. (2 0 9) <br /> Phone — <br /> Owner's Name SlIt7 Son PaDer Co. Address (916) <br /> Inc, .dba 2001 Market St. ,Rrn 523 Phone <br /> Lawrence David A. <br /> License — <br /> CorluaclarLaWrence & ASSOC. Address pESTRUCTION L1 Out of Service Well ❑ <br /> WELL ❑ WELL REPLACEMENT Cl Monitoring Well ❑ <br /> NEW ER ❑ <br /> TYPE OF WELLIPUMP: SYSTEM REPAIR C7 OTHER <br /> I PUMP INSTALLATIO Ck 'PROP. LINE +-a, <br /> > t SEWER LINES-7 111-01112-- DISPOSAL FLD,7--1 -g <br /> i DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL. <br /> PITSISUMPS <br /> F <br /> FOUNDATION __.__�— AGRICULTURE WELL <br /> PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> INTENDED USE TYPE OF WELL pia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Industrial Specifications <br /> f 0 Tracy Type of Casing <br /> CI DomesticiPrivate Cl Gravel Pack Type of Grout <br /> f:1 Other fl Delta 4 Depth of Grout Seal <br /> 'l l"1 Public Surface Seal Installed by <br /> € 1 1 lrrioation Approx. Depth l I Eastern H.P. State Work Done <br /> t Repair Wok Done U Type of Pump Sealing Material & Depth <br /> Well Destruction ❑ Well Diameter Filler Material 3 Depth <br /> Depth <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRlADDITION I I DESTRUCTION I 1 availabPe{within 200 feetit1sd if public sewer is <br /> installation will serve: Residence— Commercial— Other�� r <br /> Number of living units: 'Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity-- No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal - <br /> PKG. TREATMENT PLT. CI � <br /> Distance to nearest: WellFoundation _.PropertyLine <br /> { <br /> Total length/size <br /> LEACHING LINE C1 No. & Length of linesp,orty Line <br /> FILTER BED C1 Distance to nearest: <br /> Well Foundation __�___�� <br /> R <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Ll Distance to nearest: Weil <br /> Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> F i her certify that i have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin County <br /> 1 Home owner or licensed agent's signature oenifies the following: "I certify that in the performance of the work for which this permit is issued, I signature <br /> she not <br /> s of California," <br /> empso sthe following:person <br /> such <br /> cemannery that n the pertorrnancesubject <br /> of the work workman's <br /> wh ch this permit law <br /> is issued, I shall employapersonslsubj sring ubject to workman's gCompansa <br /> cern <br /> tion laws of California." <br /> The applicant, sl call for all requd inspections. Complete drawing on reverse side. <br /> .—� <br /> Title: President Date: <br /> Signed X _ <br /> OR DE FITME 5 NLY <br /> Date � a <br /> Application Accepted by <br /> F Final Inspection by � <br /> Date <br /> Pit or Grout InspecWn by Date <br /> Additional Comments: <br /> San Joaquin County Public Health Services <br /> Applicant - Return all copies to: <br /> Environmental health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> ' AER <br /> DUE AMOUNT REMITTED <br /> CK RECEIVED by DATE PERMIT'NO. <br /> f /_ 3_ <br /> �5 <br /> F EH 13.24 1pEv."Pts)14.26 <br />