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�nn SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES V �� ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 1 , PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby [Wade 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. ob Address +� City Jam`L7LfK I C V Lot Size/Acreage Owner's NamaKeleS Address 39 1 4 £' yA_ V' _ Phone Contractor q A Address 39 d E. '04 8 License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION c Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 13monitoring Well C7 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dis. of Well Excavation Dia. of Well Casing r_1 Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing_ Specifications I'] Public 17 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE Of SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION ldtl)ESTRUCTION (No sepiic.system permitted if public sewer isr, % I vailable within 200 feet.) `� Installation will serve: Res'idence�� Commercial — Other Number of living units: Number, f bedrooms ` Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK © Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑.« __e_. _,_.„.,,,_� �— Method of Disposal Distance to nearest: Well ndation Property Line LEACHING LINE CI No. & Length of lines rotal length/size FILTER BED n Distance to at: Well Foundation erty Line l SEEPAGE PITS 1 1 epth Sire Number SUMPS Ll Distance to nearest: Well Foundation Property Line ; DISPOSAL PONDS ❑ 1 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 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 subje#to workman's compensa- tion laws of California." , The applicant must call for all required inspections. Complete drawing on reverse side. �( Signed X L _ � — Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by ` Date" Z Area Z Pit or Grout Inspection by Date Final_Inepect�� by . A � Dato Additional Comments: O "ti• t' 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 t FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. /INFO M Eff l7.2<IREV.Iinsl b94� EH 71-211 171