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.3 SAN • QUZN COUNTY PUBLIC HEAL xHNVIR0NMENTAL HEALTH DIV S&, 00166 445 N SAN JOAQUIN, PHONE (20 )464'4420 P O BOX 2009, STOCKTON, CIA Y N as L4 PERMIT EXPIRES 1 YEAR FROM D T9W&ED (Complete in Triplicat, ) ! /7&7 Application Is hereby made to Sm Joaquin County for a permit to construct an for insta% I'll! - application is made in colnpilance with San Joaquin County Ordinance No. 549 snd�6i-rtd' e o nn Joaquin County Public Health Services. 9-7 [7 i t. Job Address rR / ( I 011'/'7'x'' City 1,i I')C1,l91 Lot Size/Acreage.�,I`3 !^r!C S Phone Name Add,resss 03 5 1) &? n gez Contractor Address �Phone i r / /� � TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ Ne, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS V ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t� [l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications v 1'I Public 1.1 Other 11 Delta Depth of Grout Seal Type of Grout r. I I Irrigation _Approx. Depth I I Eastern Surface Saul Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material L Depth ! r TYPE OF SEPTIC WORK: NEW INSTALLATION iA REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence X- Commercial_ Other r Number of living units: ( Number of bedrooms 3 - Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity� No. Compartments PKG. TREATMENT PLT. ❑ ! Method of Disposal r Distance to nearest: Well ` Foundation Properly Line,_ 17 LEACHING LINE W No. L Length of lines — Total length/size I. FILTER BED ❑ Distance to nearest: Well Foundation Property Line V SEEPAGE PITS Z Depth / Size .4-1 f7 /!c. Number I(A-�> (!�) v sr SUMPS LI Distance to nearest: WellFoundation Properly 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 Sen Joaquin County roe 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 runner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting 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 compenss tion laws of California." r The applicant must call for all re i ed in per ions. Complete drawing on reverse side. Sign. Title: eLS I f✓") p� Date: r. FOR DEPARTMENT USE ONLY Application Accepted by _. Date �� Area r it Grout Inspection by Date Ij Final Inspection by Additional Comments Applicant - Return all copies to: San Joaquin County Public Ilealth Services Environmental health Permit/Scr.tces 445 N San Joaquin, P O Box 20^9, Stkn, CA 95201 Lf2-r FEE AMOUNT DUE AMOUNT REMITTEDPECE"✓ED 9Y I DATE PERMIT N0.