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SAN JJQUIN COUNTY PUBLIC HEALTH S ICES V I RONMENTAL HEALTH D I V I S I OM T H 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSU u (Complete in Triplicate) pp��nn�� 2 , n Application in hereby made to San Joaquin County for a permit to construct and/or install theltlork he ein�d�cribed. 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. q4Z SA S4�>�,on AV ENVIRONMEN EAUH Job Address r - City_RtPo ____ Lot SiAiR�K,,q 2— Owner's Name ('_ Address �1��_��3 G�-, Phone Contractor ! ' ` CA19LC0J (CAI q-��,, ddress icense No. 53�4¢� Phone V4k_11 TYPE OF WELL/PUMP: NEW WELL X, WELL REPLACEMENT Cl DESTRUCTION Cl Out of service Well 5 PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER O Monitoring Well �( DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE __ �`� FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Sem r-., (fir '- 3 ffQ Industrial ❑ Open Bottom Elation -5 Manteca Dia. of Well ExcavDia. of ell Casing (1 Domestic/Private f:R Gravel Pack U Tracy Type of Casing Specifications Specifications I'I Public (I Other fI Delta Depth of Grout Seal r_L� � T _ I I IrriOation 3Qw�A --- Type of Grout n E pprox. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material 8 Depth Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. b Length of lines Total length/size n FILTER BED CI Distance to nearest: Well Foundation Property Line _fl `-s F�AR4 199-2 SEEPAGE PITS 11 Depth Size __ Number SAN I AA@{-IIN COUNTY SUMPS LI Distance to nearest: Well Foundation Property Line PUBLI HEALTHSFRVICFS DISPOSAL PONDS ❑ vE� IRONMENTAL HEALP N 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." The applicant ust- ca-11 for requiirred�' sppeections. Complete drawing on reverse side. / Signed X.'� /71�i� Title: Date: Zi! r FOR DEPARTMENT USE ONLY Application Accepted by G w Date "-1- '0 L CD 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 \CK `CAS H RECEIVED BY DATE PERMIT'NO. EH 13 24 INFO ��^!, q (�/ ^S • EH 14-26tREV.r�N51 Y'l V 1 r T) I . �.J 3✓�� " _ 9c4�s�