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SAI OAQUIN COUNTY PUBLIC HEALTH r,CRVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOA 2009, STOCKTON, CA 95201 ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application In hereby mad* to San Joaquin County for a permit to construct and/or install the work herein deeerlhed. This application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. n� ` City Job Address J _J 1(,-, (4 ,�u tZ Ne R Vcl �_ _r__—_ Lot Size/Acreage _��r-a �_______. Owner's Name G q ga '1 -Z- Address ep �)_CA_�_►�e 2 f C1 Phone rorilr.lctod it--4 h Address L License Noz��9-��i _Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION-K Out of Service Well O PUMP INSTALLATION O SYSTEM REPAIR OTHER [I Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Il Industrial C1 Open Bottom ❑ Manteca Dia of Well Excavation Dia. of Well Casing [I Domestic/Private Ll Gravel Pack Ll Tracy Type of Casing_ Specifications I'I Public ( I Other I-1 Delta Depth of Grout Seal Type of Grout I I Irntlation __ Approx. Depth ( I Eastern Surface Seal Installed by Renoir Work Done U Type of Pump H.P. State WoT. r�,.OorlB Well Destruction Well Diameter r Sealing Material i Depth Ulti 1.1 r] S Depth !61_�, r Filler Material i Depth r-r)&_ V�_ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I INo septic system pernvtted if public sewer is available within 200 feet.) 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 SEPTIC TANK O Type/Mfg Capacity_ No. Compartments PKG. TREATMENT PLT. f_l Method o1 Disposal _ Distance to nearest: Well Foundation Property Line=— --_ — I.EACHING LINE Cl No. 8 Length of lines Total length/size FILTER BED I7 Distance to nearest: Well Foundation _ _ Property Line _.. -- SEEPAGE PITS 11 Depth __ Size _ Number _ SUMPS t.1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Ll 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 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 compensa tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signet) Title: �� Date: ARTMENT USE ONLY Application Accepted by _t' ,,.� r �t.�v� Date Pit or Grout Inspection by Date Final Inspection by Additional Comments: Applicant - Return all copies to: San Joaquin County Public health Services Environmental Health Permit/Services i� 445 N San Joaquin, P O Box 2009, Stkn, OA 95201 FEEi INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. -, IF 14 taEv r,a s, W 10 0 J ! S�(2.V� 143$ 7—) L_ /rJ Yv "o