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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 r PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r Application is 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r Job Address p ` p' ° "� � City Lot Size/Acreage 1;2 L4L'12.A� Owner's Name x�,-Oo- E r `.� Address Phone Contract Address License No. Z Z4= Phone `y /c+S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ Ise DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE \ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r\ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y t, ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing /v P Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications (� I'I Public ❑ Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed byass �1 Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material & Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR ADMTIONA DESTRUCTION I I (No septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence 1 Commercial_ Other Number of living units: L Number of bed - s �d Ise 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 Property Line \'(� LEACHING LINE ❑ No. 8 Length of lines Total length/size �V r FILTER BED ❑ Distance to nearest: Well Foundation Property Line ` it SEEPAGE PITS Depth C251 Size Nymber - SUMPS LI Distance to nearest: Well 100' Foundation 10 Property Line S DISPOSAL PONDS ❑ 1 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 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: "1 certify that in the performance of the work for which this permit is issued, 1 shall employ persons subject to workman's compensa tion laws of California." The applicant st call to 9re u ad inspections. Complete drawing on reverse sid �y1 Signed X f Z- Title: Date: I FOR DEPARTMENT USE ONLY w Area J Application Accepts d by y Date 2�9 �^ Oir Grout Inspection by Inspection by�-�r ��r-tf� Date ® Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stku, CA 95201 r FEEAMOUNT DUE AMOUNT REMITTED CKeTQ ECEIVED BY DATE PERMIT'NO. NFO nnJJ7� 14 EM c3-7a(REV.1r951 v"/ • (1 �. EH to as fJ r