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I % r I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I Application is hereby made to San Joaquin County for a permit to construct and/or install the vont herein described. This application is made in compliance with San Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Q'�� Job Address City�_-- Lot Size/Acreage Owner's Name oE Address Ir►1� J� Phone ��/� Contractor y.) Address License No Phone /V TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION Li Out of Service Well 0 PUMP INSTALLATION W " SYSTEM REPAIR/Ll OTHER C] Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fT]romestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications U1 Public 1-1 Other C) Delta Depth of Grout Sea! Type of Grout I I Irrigation _..Approx. Depth I I Eastern 5u/rrface Seal Installed by Repair Work Done L7 Type of Pump f!(.a H.P. /7 � State Work Done Well Destruction ❑ Well Diameter Seaii al & Depth_ epth W 97-6L ( ' Depth Filler Material & Depth su t�L TYPE OF SEPTIC WORK; NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I 1 fNo septic system permitted if public sewer is available within 200 leet.j Installation will serve: Residence— Commercial— Other , QNumber of living units: Number of bedrooms j 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: h Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Prdperty Line SEEPAGE PITS 11 Depth Size f Number's SUMPS LI Distance to nearest: Well Foundation ' /Property Line DISPOSAL PONDS ❑ r �' 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 I ' ,i_ ^ Home owner or licensed agent's signature certifies the following: 1 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." Contractors 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 tc workman's compensa- tion laws of California." The applicant all for all required inspections. Cgnplete drawing on rev Signed X Title: Date: [�� 1 OR DEPARTMENT USE ONLY 3 Application Accepted by - Date Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Bax 2009, Stkn, CA 95201 AMOUNT DUE AMOUNT REMITTED CASH K I RECEIVED 9Y DATE PERM17'N0. . EH 11CZ(REV.i in siIE4tO EH t�•]e 1