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T APPL-I CATION SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES /+� ENVIRONMENTAL HEALTH DIVISION if A PUCKETT'S PUMP & WELL SERVICE 445 N SAN JOAQUIN, PHONE (209)468-3420 lk �, `1Vr p.0. BOX 602 LINDEN, CA 95235 P O BOX 2009, STOCKTON, CA 95201 APIC �vieo CONT,L►�. 0521666 czog>�-5%9 � 1993 ) PERMIT EXPIRES I YEAR FROM DATE ISSUED SANJpA � (Complete in Triplicate) ENVIRQNMEJH�!T�4LTHSpUN�y Application is hereby made,to San Joaquin County for a permit to construct and/or install the work hePi�l�1421 f� 1��' is application is trade in compliance vith San Joaquin County Ordinance. No. 549 and 1862 and the Rules and Regu t f�ptl, Joaquin County Public Health Services. �✓�Y I t: Q I Qtr' City Lot Size/Acreage Job Address i1 n`' i7� t�1 L1 Yr� tl � �. ✓t I _ Address fit' Phone T" -7_F1 O10 wner's Name �� viL �e v P.O. BOX 602 LINDEN, CA 95236License No.�� Phone 7 Contractor TYPE OF WELL/PUMP. NEW WELL LJ WELL REPLACEMENT Ei DESTRUCTION ❑ Out of Service Well ❑ SYSTEM REPAIfi OTHER ❑ Monitoring Well p PUMP INSTALLATION El SYSTEM DISTANCE -6 NEAREST: SEPTIC TANK" ` """;SEINER LlNE5`r = DISPOSAL FLD.- � .PROP:•LINE . s _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE Ol�WELL PROBLEM AREA "CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom 0 Manteca Oia. of Well Excavation Dia. of Well Casing KDomestic/Private El Gravel Pack El Tracy Type of Casing_ Specifications I,.I Public (-I Other # Cl Delta Depth of Grout Seal Type of Grout I i Irri anon __.Approx. D9pth l 1 Eastern Surface Seal installed by g 11 ` 1'�"Y_ Repair Work Done 0 ,Type of Pump �J H.P. State Work Done R Well Destruction ❑ Well`Diameter Sealing Material ! Depth Depth AFiller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITiON I I DESTRUCTION I i Mo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ _ Commercial— Other i Number of living units: N�mber of bedrooms Character of soil to a depth of 3 feet: Water table depth !!! SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG.,TREATMENT PLT. 0 Method of Disposal ' Distance tonearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED El Distance to nearest: Well Foundation Property Line I SEEPAGE PITS l I Depth I Size a Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 i I hereby certify that I have preparedlthis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and-3— rules and regulations of the San Joaquin County i - 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 not 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." r The applicant �s call for all req co r d ins ons. Complete drawing on reverse side. Signed X Title: .t�lvcQ11 __-- Date: r FOR DEPARTMENT USE ONLY Application Accepted by Date Area l' 9 Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all clopies to: San Joaquin County Public Health Services Environmental Health Permit/Services .. 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT O,6E AMOUNT REMITTED CASH RECEIVED BY DATE PERM17•NO. I FO . El17.21[REV. ✓f EH 14.201 ©CJ 'tIf GQ r ,.27 V//rLf 4