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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in coupliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Heal- th Services. Nil ob Address 42/C)--> �N City 5n:!.-Lot Size/Acreage 6� l r X0,wner's Name iy�,� Address Phone J`Conlractor r / �n�'�� Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEME C1 DESTRUCTION El Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REP IR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEW LINES - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL RE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA C ST UCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom ❑ Manteca Dia. Well Excavation Dia. of Well Casing f I Domestic/Private ❑ Gravel Pack ❑ Tracy Ty of ing_--- Specifications 1'I Public FI Other fl Delta pth of Gro Seal Type of Grout r I I Initiation __ Approx. Depth I I Eastern Surface Seal Insts d by Repair Work Done U Type of Pump H.P. ate Work Done _ Well Destruction ❑ Well Diameter Se ing Material Z Depth ,(� Depth Filler Material i Depth . FFILTER F SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sower is available within 200 lest. ation will serve: Residence �Commercfel _ Other er of living units: Number of bedro ms � � cter of soil to a depth of 3 feet: ��---( Water table depth TANK O Type/Mfg opacity No. Compartments PKG. EATMENT PLT. ❑ Method of Disposal Distance to nearest: II o2DOI Foundation LQ P operty Line �:t-- L i raj NG LINE ❑ No. 6 Length of lines I Total I ngth/size_ ,- BED ❑ Df9tance ttf nearest; Well Fo ndation Property Lin! BO E PITS II Depth Si:e _ Number LI Distance to nearest: Well Foundation Property Llns AL PONDS ❑ 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 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: "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." /T'he applicant must call II uired Ina tons. Complete drawing on reverse side. ��(Signed X Title: Date: Z z/ �� DEPARTMENT USE ONLY Application Accepted by r. 1�..wt1.-y Date Z Area Pit or Grout Inspection by Date Final Inspection by Datb�� 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, Stkn, CA 95201 FEE CK INFO AMOUNT DUE AMOUNT REMITTED /C�_AS_Hfe_ RECEIVED 9Y ^l,DATE PEERM17 NO. �j\ • EH 17 21(REV. i n 51 I r O D O� WV� ` ✓ t � 9` `v { V EH t4 2a