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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES " ENVIRONMENTAL HEALTH DIVISION 445 N SAN JQAQUIN,„ PHONE (209)468-3420 P O BOX 2009',- STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County fora 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 Re lations of San Joaquin County Public Health Services. r /�� /f�6 ,5 /s��,a.� Job Address ��• •� �"� ~ City a 101"`lttSt Size/Acreage Owner's Name x � ��O L 1?] eT f� /j / 3 Contract U r Address�� IT�� License No.14 ZO 3 7c3Phone Z TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 17.1 DESTRUCTION ❑ Out of Service Well D PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring �/ Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i TENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca' Dia- of Well Excavation Dia. of Well Casing n Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ Specifications-- -- I'i Public F1 Other f-1 Delta Depth of Grout Seal Type of Grout I I-Irritjation %Approxi DepthI J/rrstern Su Soul installed by Repair'Work-Donees ,,;-''.type O'f-t ump- 44eCZ H.P. State Work Done Wel! Destruction ❑ Well Diameter Sealing Material rte Depth i Depth__- . rJ Filler Mate ria l.& Depth TYPE OF SEPTaC WORK:_NEIN 1NqTALLATION I 1 REPAIR/ADDITION.I I`-DESTRUCTION i I INo septic system permitted if public sewer is {'available.within 200 feet.! Installation;will serve: :`Ftpsiilence_.. mrne3reial Other Number of living;unitst: ' Number of be ems "Character of soil to a depth of 3 feet: Water table depth SEPTICTANK ; ❑ Type/Mfg ' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal _ Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of tinesTotal length/size — FILTER BED ❑ Distance to nearest ell Foun on Property Line 1 SEEPAGE PIT9 11 Depth Size Number SUMPS; Ll Distance to ne st: Well Foundation Property Line d 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, and rules and regulations of the San Joaquin County Home owner or Ii nt'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, on in such ' hner-as,(o become subject to-workman's compensation laws of California.” Contractor's.hiringot sub-contracting signature certifies't 016ving:1' cert that in'the pertormanj#of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion law of California." The ap licant u r all r Co late drawing side. +� Signed Title. Date: =2 x F DEPARTMENT USE ONLY R Application Accepted by Gel- Date Area Pit or Grout Inspection bys Date Final Inspection by Date 93 Additional Comments: 3 1 Applicant - Return all copies to:, ,an Joaquin'County Public Health Services Environmetit&l Health Permit/Services 445 N San Joaquin, P O Box 2009, Stka, CA 95201 IFEE NFO AMOUNT DUE AMOUNT REtdlTTEO • CASII RECEIVED BY DATE PERMITNO. . EH 13.24 IRev.I/n 5)Y 0 ✓'_/ ' ��o V EK 11.1E