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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 I (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 trade in comrpliance'vith San Joaquin County Ordinance No. 549 and 1$52 and the Rules and Regulations of San Joaquin County Public Health Services. +-�; Job Address � I �� City 1 `"��Lot Size/Acreage (07( Owner's Name � Address / O /�+ I �CX Phone &-3 f I jddress� ContractorE .1[`P Ad � f"W44License No.V2,2�Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 171 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fa Domestic/Private ❑ Gravel Pack` ❑ Tracy Type of Casing_ Specifications U1 Public is Other (l Delta Depth of Grout Seal Type of Grout 1 I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by i Repair Work Done L7 Type of Pump H.P. State Work Dona _ Well Destruction ❑ Well Diameter ) sealing Material & Depth Depth Filler Material & Depth 1 TYPE Of SEPTIC WORK; NEW INSTALl.ATiONI REPAIAlAODITION l I DESTRUCTIONX INo septic system permitted if public sewer is 0 available within 200 feet.) l Installation will serve: Residence X Commercial— Other Number of living units; —I— Number of bedroom _ Character of soil to a depth of 3 feet: r Water table depth SEPTIC TANK ❑ Type/Mfg �I P Capacity No. Compartments PKG. TREATMENT PLT, Elr I ethod of Disposal Distance to nearest: Well _ Foundation _1Q I;—'- Property Line � 74- LEACHING LINE' L� No. & Length of lines Total length/size FILTER BED [Distance to nearest: Well 0,20-04- Foundation Jsrl Property Line i SEEPAGE PITS I I Depth T Size _ Number SUMPS Ll Distance to nearest: Well Foundation Property Line Y 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 f.hat 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 taws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify tha to t rtormance of the work for which this permit is issued, I shall employ parsons subject to workman's compensa- tion laws of Californ ' The applicant st call all ul ed ins' tions. Onmpl t drawing on reverse sid , Signed Title: .,,. Date: F DEPARTMENT USE ONLY Application Accepted by Date 2, Area 2• Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: be, r �t-^� l Applicant - Return all copies -to: San Joaquin County Public Health Ser ices ©_[� t "-�� COPi �� Environmental Health Permit/Services 445 N San Joaquin, P 0_ ox 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUN REMITTED CAS CK RECEIVED BY DATE PERM11'NO. • EM14.21 Il1EV.I/+tSY b 1 , ,�\ f I EH 1i•20 8 v