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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 U2l� 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 County for a permit to construct and/or install the work herein described. This application is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. J /'1 /� Job Address City S. r �Lot Size/Acreage L V ` Owner's Name 'A � Ad [dress `�'� Phone 313 °0 � Addres f License No Phone 3 T_�� Canhactor — � r TYPE OF WELL/PUMP: NFW WELL WELL REPLACEMENT Cl DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION-TT SYSTEM REPAIR D OTHER ❑ Monitoring Well G7 DISTANCE TO NEAREST: SEPTIC TANK 610 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial IIIOpen Bottom ❑ Manteca Dia.of Well ExcavatQn 01 Dia. of Well Casing�4� '-FiL'Domestic/Private - . Gravel Pack 0 Tracy Type of Casing_ ✓—+�� Specifications I'I Public 1-1 Other " 171-Delta _ Depth of Grout Seal C"r� Type of Grout 1=&A M� — I I Itrigation o—VO .Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U. Type of Pump SX47 H.P. Z State-Work-Done 7A-- 8 fit&� Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material a Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION i I iNo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence— Commercial— Other { ll f Number of living units: Number of bedrooms i Character of soil to a depth of 3 feet: Water table-depth SEPTIC TANK. O Type/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 [a t'Distance to nearest:,. Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ s I hereby certify that I have preparedihis-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 Cot nty�, Home owner or licensed agent's signature certifies the folloVing: "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 f certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons�ubject to workman's compensa- tion laws of California," The applicant must c I for required inspections. Complete drawing-on,reverse side. �j Signed X - —_— Title: ��^'� - _ - Date: F R DEPARTMENT USE ONLY Application Accepted by Date Area �^`2. 'tl1Final Inspection byr 'Date Pit o out ns ction by Date ��_ p nro r 1 - 26 � Additions omments: AA — Applicant - Return all opies to: San Joaquin County P blic Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 CK FEE AMOUNT CE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO .®a 4.28 ( Q3 -0$7 . EH 53-]4 tREV.t/K 5 WPA) Ll,5 r�� l,.J 7 3/3 ll EH 1