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:- _..f 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 1662 and the Rules and Regulations of San Joaquin County Public Health ServicesIhIC2 ti 11 b _P L04 Job Address p I City Lot Size/Acreage Owner's Name 6� �`-�' Address Phone 40( Cant7�tor �Ad v�� ice nse No. Phone TYPE Of WELL/PUMP: NEW WELL WELL REPLACEMENT1-1 DESTRUCTION ❑ Out of Service Well LlLLATION PUMP INSTASYSTEM REPAIR 0 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 Ac ustrial ❑ Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing mastic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specification1 iPublic Ll Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. pep l I Eastern � Surface Seal installed by Repair Work Done U Type of Pump H.P. Lo State Work Don Well Destruction ❑ Weil Diameter Sealing Material & Depth Depth w -- Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted it public sewer is available within 200 feet.i 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. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line Y LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS Ll 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 appl�icl must ca 11 all required insPections. Complete drawing on rev se sicl Signed`fi a � W _ _ Title: Date: OR-DEPARTMENT USE ONLY Q lam? �1 Application Accepteded by u_ Y Date Rr:1 L9�fZ- Area Pit or Grout Inspection by Date Final Inspection by T`d ',��( S,r(_ Data � � Additional Comments: / {� Applicant - Return all copies to: San Joaquin CountyPublic Health Services Environmental Health Permit/Services 445 N San Joaquin,,-P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE INFO CASH PERMIT'NO. . EN13.24 IREV.i i n at 1 M `oo / EM t4•Ie 1 � �f