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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 install the work berein described. This application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health�Services. li_ I Job Address I I ork6o.± City Lot Size/Acreage n Owner's Name rh�� Vo-my: —.— Address Z�� r S�. LOCkk� Phone r pp9 IE Contractor Address License leo. s5Z t Phone d�] TYPE OF WELL/PUMP: I�' NEW WELL ❑ WELL REPLACEMENT r7 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well C7 '!p DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE _WELLOTHER WELL__ PITS/SUMPS �� INTENDED USE ± TY4!16F WELL{ PROBLEM AREA CONSTRUCTION SPECIFICATIONS _ n Indu'strial', ❑ Operil Bottom © Manteca Dia. of Well Excavation Dia. of Welt Casing Domestic/Private ❑ Gravel Pack t.7 Tracy Type of Casing_ Specifications CPublic t 1 11 Other 171 Delta Depth of Grout Seal t Type of Grout 11 Irrigation __,A`pprox . Depth l I Eastern S rface Seal Installed by Repair-Work Done f 7 !Type of,iPum H.P. State Work Done _ �G�. Well DAsfruction ❑ "'Well Diallmetep !" 0 Sealing Material a Depth { Depthil / � Filler Material & Depth TYPE OF SEPTIC 41/ORK: NEW;INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I i iNo selitic system permitted if public sewer is IIi available within 200 feet.) Installation will serve: Residence_ Comrrtercial_ Other p Number of living units: Number of ibedrooms Character of soil to a depth of 3,�'eet: I Water table depth SEPTIC TANK O Type/Mfg Capacity No. COF04WIS Q# PKG. TREATMENT PLT. ❑ ry Metho �I VED j Distance to nearest: Well Foundation Property Line 'IT, t92 LEACHING LINE I1 No.,&! L66gth of lines Total length/siz) ILII FILTER BED [7 Distance to neatest: Well Foundation ProperWC HEALTFi SERVICES ENVIRONMENTAL HEALTH DIVISION SEEPAGE PITS l I Depth `- s Size Number SUMPS LI Distance io neatest: Well Foundation Property Line "-DISPOSAL�PONDS+- • +p..r, -Y% ;. - . �.— I hereby certify that 1 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 t 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 shah not employ any person in s ch rnannef as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature t certifies the fo certify that'in the perf6rmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of aliforni The applicant t or all required t,,1,,,nsJplete drawing o rev sideSigned Title: Date: .._ __ _ _ FOR DEPARTME USE ONLY � � P Application Accepted byDate Area Pit or Grout Inspection by I Date ' Final Inspection by Data r A -Ad'diiionahComments: ripF i� Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services i H 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DIGS AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. . EHt3.74tREV.tinslP� f; �l�rit EH tl-Ia i s I -