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APPLICATION PUCKETT'S PUMP&WELL SPOViOE P-0. BOX 602 LINDEN, CA 95236 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES CONT. LIC. 052166F4(209)9445969 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. SJob Address n + � �r City 1W Lrot Size/Acreage Owner's Name �J v �""t uYrOn Address SQOK-F,_ Phone131— a PUCKETT'S PUMP& WELL SERVICE {� d Contractor P.O. BOX 60_2 LINDEN, CA a�,�i4dress License No. Phone er.. ..— TYPE OF WELL/PUMP: t"11IE 9❑ WELL REPLACEMENT Cl DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 'E OTHER ❑ 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 C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing .k Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'1 Public 0 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Dept I i Eastern Surface Seal Installed by Repair Work Done Type of Pump H.P. State Work Dane �ia(7 Well Destruction ❑ Well Diameter Sealing Material & Depth Depth 150 Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INa 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: Walt t SEPTIC TANK ❑ Type/Mfg Capacity No. 1 PKG. TREATMENT PLT. 0 Met Distance to nearest: Well Foundation Property l p n in A ann MN LEACHING LINE Ci No. & Length of lines Totai lengtrQt- U JOAQUINCOUNTY FILTER BED [? Distance to nearest: Well Foundation DIVISION SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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 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 call for all re ired insPections. Complete drawing on reverse side. Signed Title: Date: R D ARTfN U5E ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by A Date 97 Additional Comments: Applicant - Return ail copies to San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE s INFO AMOUNT DUE AMOUNT REMITTED CK ECEIVED BY DATE I PERMIT N0. . EH 13.24 fREV.,ix5) �J 5,_ / EH 1�2e4L