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- SAN JOAQUIN COUNTY PUBLIC HEALTH S-mAVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-5420 C D P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in 'Triplicate) Application In 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address r �/ - ='� City [) tr Lot Size/Acreage 1 ' Address Name kr_(. Phone or ' uAddress F� ��A / License No. P hone� 1 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER Ll Monitoring Well C] DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE ! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 171 Domestic/Private Ll Gravel Pack ❑ Tracy Type of Casing_._ Specifications I') Public 1.1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation —,_ Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done 11-7 Type of Pump H.P. State Work Done _ J Well Destruction ❑ Well Diameter Sealing Material & Depth V Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIONINo septic system permilled if pubfic sewer is available within 200 feet.) C� Installation will serve: Residence — Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth. 1 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments 111 PKG. TREATMENT PLT. O Method of Disposals 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 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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 u 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, 1 shall n r 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 requited inspections. Complete drawing on reverse side. Signed X a 7- ' ► , ► t°., ' Title: __ jl -Qc� w Dain: FOR DEPARTMENT DEPARTMENT USE ONLY v f � l Application Accepted bye' - T Date _(-_a__ __ Ij 2 Area �_- Pit or Grout Inspection by a Final Inspection by� Date��9L Additional Comments: 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 FEE AMOUNT DUE AMOUNT REMITTED /CASH CK RECEIVED BY DATE PERMIT'NO. EM 13-24 EH 14,28 EV.rin 7 ,� � V�