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_ r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1445 N SAN JOAQUIN, PHONE (209)468-3420 ;I P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 1 Application is hereby made to S"�Josquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance o. 549 and 1862 and the Rules and Regulations of San Joaquin County Pub c Health Ser' S. Job Address City L Size/Acreage 9aowner Is Name o e i � C n c r 5 c a. Phone ..- TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT n1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATIO SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ 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 M dustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Welk Casing bmestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'i Public fa Other n Delta Depth of Grout Seal Type of Gro t I I Irrigation __.Approx.iDe I i astern ' riace Seal installed by Repair Work Done U Type ofEPum l�/> H•P• State Work Well Destruction ❑ Well Diameter Sealing Materiel & Depth Depth ► t Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I INo septic system permitted if public sewer is t available within 200 feet.) Installation wiff serve: Residence_. Commercial= Other Number of living units: N"r`ber of bedroomsv Character of soil to a depth of 3 feet: Water table depth \l SEPTIC TANK. ❑ Type/Mfg—Capacity No. Compartments V PKG. TREATMENT PLT.❑ 'T`` Method of Disposal f Distance to nearest: Well Foundation Property Line !* [Total length/LEACHING LINE Li o; & Length of lines g p FILTER BED .n—Distance to nearest:+i.�Well�----_ --Foundation i Property Line C SEEPAGE PITS 1 1 t, Depth Size ''~ - �* t Number ' La�Distance-to-nearest:----.•-Well ` perry- '� SUMPS -....�.�..-..Y-,..,� —�--^----�Fouradatian�-------�------�Prri L-ine----- " DISPOSAL PONOS ❑ 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, I shall no employ any person in such manner as to become subject to workman'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." F The applican call for a ed inspections. Complete drawing on re se side. AfSigne Title Date: F DEPAR E ONLY Application Accepted by Date Pit or Grout inspection by Date Final Inspection Data�� Additional Comments: 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 i CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. INFO A )/� �lq� ♦ CH 120IREy.1{wtSl SrQ�rJ �r!� g 10 20 �� EH 14., f`26 [