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. t , SAN JOAQUIN COUNTY�PdBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 P1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �vvL Pe'a,L/ Yo-- I (Complete in Triplicate) t 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 with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Q le City Lot Size/Acreage it k Owner's Name Address �� Phone Contractor d S�Address / //��/ P— L+cense Ne v Phone TYPE OF,-WELL/PUMP: NEW WELL 11 WELL REPLACEMENT ❑ DESTRUCTION Cl Out of Service Well ❑ 1i I PUMP INSTALLATION ❑ SYSTEM REPAIR;k— 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 n Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing x0lomesticlPrivate Cl Gravel Pack C1 Tracy Type of Casing_ Specifications \\ ❑ Delta Depth of Grout Seal Type of Grout I') Public f 1 Other I I I Irrlgation _ Approx. Aepth I I Eastern Surface Seal Installed by Repair Work Done )!r Type of Pump LF—C-0— H.P. State Work Done : C.)P � Well Destruction ❑ Well Diameter i Sealing katerial & Depth Depth I 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 1 available within 200 feet:} Installation will serve: Residence_ 1rrCommercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg I s' Capacity No. Compartments + PKG. TREATMENT PLT. Cl Method of Disposal Distance toinearest: Well Foundation Property Line - LEACHING LINE 1 ❑ No. & Length of lines Total length/size - FILTER BED CI Distance to nearest: Well Foundation Property Line r I a^^ 3 i SEEPAGE PITS 11 Depth Size Number SUMPS 0 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, state laws, an A rules and regulations of the San Joaquin County t . x 11 Home owner or licensed agent's signature certifies the following: "I,certify tliat-in the performance of the work for which this permii1i issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature "C { certifies the following: "I certify that in the parlormance of the work for which•tk permit is issued; I shall employ persons subject to workman's compensa- tion laws of California." ' I The ap - nt mu call for all requir inspections. Complete drawing on rev side. Signed X Title: , .p S -- Date:, r A FOR PARTMENT USE ONLY FOR j Application Accepted by Date lA CM07 ` Area Pit or Grout Inspection by Date Final Inspection by Date 1 l`2S'"�2— ; Additional Comments. Applicant - Return all copies1to: San Joaquin County Public Health Services '1 Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 I� FEE AMOUNT DUE f AMOUNT REMITTED r CK 8J RECEIVED BY DATE PERMIT NO. INFO 19 qlal �Z� • EH 13.21 tREV.tiKsl 467 w EH 14.25 --c