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��za SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 the Rules and Regulations of San Joaquin County Public Health Services. 1 Job Address C City Lot Size/Acreage Owner's Name C v Address Phone Contractor LAAddress License PEo. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION C1 Out of Service Well in PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Y INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing NIk6ornestic/ ❑ Gravel Pack ❑ Tracy ./Type of Casing_ Specifications 1'I Public [-I Other n Delta k depth of Grout Seal Type of Grout I I irrigation _Approx. Depth I i Eassern S�urface Seal installed by Repair Work Done U Type of Pump H.P.—c,c ; �.I State Work Done T '` Well Destruction ❑ Well Diameter r Sealing Material & Depth Depth r /� Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted 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 ❑ Type/Mfg Capacity No. f� PKG. TREATMENT PLT.❑ Meti�ool� Distance to nearest: Well Foundation Property I f JT 2419402 LEACHING LINE ❑ No. & Length of lines Total fengthA-A FILTER BED ❑ Distance to nearestd(m '>, Well Foundation Prbwn W Ai TI-- �-�cFYJ /JC%S ENVIRGiVP,EIEN ALHEA1J'H i1Lylgohi SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well, Foundation Property Line pISPOSAI 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,an-1c— 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 anyper o in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the o ow ng: "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 C i rnia." The appfi t ust call for all r i ed inspe, io s. Complete drawing o ve a side. i Signed Title: Date: o- r FOR DEPAIRTME T USE ONLY Application Accepted by Date w 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 O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. INFO EH 13.24 IREV,i a 5)PP 70 &V EH 14.26 r ��