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i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH -DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �' bxo ' city Lot Size/Acreage Owner's Name Address I Phone Contractor ' Address License N Phone TYPE OF WELL/PUMP: O�NE9VWELL — / WELL REPLACEMENT it DESTRUCTION Cl Out of Service Well C1 PUMP INSTALLATIO I SYSTEM REPAIR C] OTHER G Monitoring Well L1 DISTANCE TO NEAREST: SEPTIC TANK 414,LAUWER LIWS DISPOSAL FLD. PROP. UNE FOUNDATIO AGRICULTURE LL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO S L7 Industrial pen Bottom ❑ Manteca Dia. of Well Excavati n ! Dia. of Well Casing Ea Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing. Specifications Il Public Cl Other n Delta Depth of Grout Seal Type of Grout r� I rrgation �,Approx. Depth I I Eilstern Surface Seal Installed by F ; Repair Work Done U Type of Pump P. �"S�7State Work Done _ �J Well Destruction O Well Diameter __� 1 Sealing Material & Depth Depth _ _A190 _ Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1'I. REPAIR_ /ADDiT;ON I i DESTRUCTION I i Mo septic system permitted if public sewer is aVailabld-within 200 feet.) - 0 Installation will serve: Residence_ Commercial _ Other Number of living units: Number of bedrooms 01) Character of soil to s depth of 3 feet: Water table depth SEPTIC•TANK O Typa/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to neerest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total leng h'lsize' FILTER BED ❑ Distance to nearest:: Well Foundation Property Line SEEPAGE PITS 1 ) Depth r Size Number 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, stete'Iaws, and rules and ragulations of the San Joaquin County Home owner or ficensad agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employaiiy person in such manner as to become subject to workmen'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." r k The applica pe, ti t t call for i1 req 'r insons. Ccynplete drawing on r rse aid Signed Title: Date: R DEPARTMENT USE ONLY Application Accepted by a p� Date 7-- LJ Area Pit or 6t Inspection by "` Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services +'J� Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 r - FEE AMOUNT DUE r AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH r • EN 13.24 I REV.k r n 5) EH 14-M a'7