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APPLICATION SAN�JOAQUIN COUNTY PUBLIC HEALTH RVICES 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 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 tgte Rules and Regulations of San Joaquin County Public Health Services. Job Address s� Cityr��J Lot Size/Acreage T S� / Address 0 D G/�S! jl+cJ Phone Owner's Name , r Rawc p t-44;rcx�) C-4 9s7V2- Contractor � Address 3 Ft r2 License Nom 7SS�f`179Phone �6 727 TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 17 DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ M0-,d.&ZTHER>� Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK -& SEWER LINES �a r DISPOSAL Fj D. NAS PROP. LINE FOUNDATION 29e AGRICULTURE WELL OIiV�E��f_.. PITSISUMPSAW INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS fl, n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation J2 " Dia. of Well Casing 6 Cl Domestic/Private ❑ Gravel Pack 'Tracy Type of CasingSc�'40 Ql1L Specifications "�✓1� I"I Public �OtherE>C-�v�L 1� Delta Depth of Grout Seal O —:3 Type of Grout NEI- i I irrigation 4 IApprox. Depth I I Eastern Surface Seal Installed by Well H rXZ 'b1. 1 tI Repair Work Done U Type of Pump H,P. __— State Work Done_ Well Destruction O Well Diameter Sealing Material A Depth Depth Filler Material i Depth TYPE OF SEPTIC W K: NEW INSTALLATIO REPAIR1ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will rve: Residence— Commercial _ Other Number of living units: Number of bedrooms Character of trail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. 6 Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL 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 taws 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 required inspections. Complete drawing on reverse side. Signed X � a=0�lT,e--ff�� Title: ?�c -esrj X57' Date: OR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'No. INFO Xr CASH �] • EH 1 .241Rfv.rinSl f 1 %32-571-ml ID 40 EH 144.71! 4