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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 Inst$ 1 the work herein described. This application Is trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County 1Public Health IServic�es 1 Job Address .�I 6 t7 A- r ""�+v` ' �� City 121 Lot Size/Acreage Owner's Name ✓V (r�i �`�! / Z �L Address �r 'Y� Phone ContractordeoC/r[1__ (940 Address�' X 1S Z License No,"�773f Phone 3 Y�9) TYPE OF WELL/PUMP: NEW WELL IE< WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION .W SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -92 PROP. LINE _11 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS L-1 Industrial r ❑ Open Bottom ❑ Manteca Dia. of Wall-Excavation—% Dia. of Well Casing ;,W Domestic/Private 'WGravel Pack ❑ Tracy Type of Casing_ tPV� Specifications —4 t1 C> 1'i Public Cl Other n Delta Depth of Grout Seal Type of Grout -CmE+Uf 1 1 Irrigation %_W— Approx. Depth I I Eastern Slace Seal Installed by a A. ti Repair Work Done 0 Type of Pump H.P. 1 State Work Dona xi 4 EK Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i 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.' ❑ Type/Mfg Capacity No.-Compartrnents PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line f J LEACHING LINE Cl No. & Length of lines Total length/size r FILTER BED Cl Distance to nearest: Well Foundation Property Line n SEEPAGE PITS 11 Depth Size Number 1 SUMPS Ll 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, 1 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 eenifies 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 ca for all required inspections, Complete drawing on reverse side. Signed _ 7/]i�ol� Title: _7(Ar�C� Date: FOR DEPARTMENT USE ONLY Application Accepted by - Date v. , Area Pit or ry Inspection by ate L Final Inspection by Date Additional Comments: �____ Sew N,4 atit, Cj09 � r - 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 CK 11 INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY_ GATE PERMIT NO. [W 0Q CI p -EM 14.21 tREV.t i n SI P N 9 3 , f 3 —I�-q317-5_ o Eli 11.26 I I