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SAN JOAQUIN' COUNTY PUBLIC HEALTH SERVICES`-,' ' ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009,. STOCKTON, CA 95201 .. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 Sn Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Cityot Size/Acreage ,} 4 Owner's Name Address / r�jE ' -- Phone r 4 i5 � contractor � G Address Q• P �i License No. _ hone TYPE OF WELL/ UMP- NEW�WELL El WELL REPLACEMENT C] DESTRUCTION ❑ out of Service Well L"} PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �OTHER ❑ Monitoring Well L7 \.-. i DISTANCE TO NEAREST: SEPTIC TANKF tT" SEWER.LINES .DISPC1SAL L'D.f PROP. LINE t,u � FOUNDATION AGRICULTURE WELL -- i OTHER WELL PITS/SUMPS i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - fl Industrial ❑ Open Bottom ❑ Manteca,7— �iDia. of-Well.Excavation_`"` __ Dia. of Well Casing t C7 Domestic/•Private ❑ Gravel Pack ' ❑ Tracy A Type of Casing_ Specifications i f I'l Public M Other ;; FI Delta Depth of Grout Seal Type of Grout I i Irrigation Approx, Depth I I Eastern Surface Seal Installdd by 1' Repair Work Done L] Type of Pump 9 H.P. Siate`Work•Done',f Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth, TYPE OF SEPTIC WORK: NEW INSTALLATION rjQr REPAIR/ADDITION I I�DESTRUCTION I I (No septic system permitted if public sewer is ,,!vailable within 200 feet.) Installation will serve: Residence Cor 1mercjai Other; Number of-living,units:.___L_� Number of-bedrooms .s,.N--��-,.ire.rs.�—�a.a�.r--.-�•.�w.:,acr. Character of soil to a depth of 3 feet: �� + -- Water table depth. SEPTIC TANK ❑ Type/Mfg R 4=hL ` Capacity No. Compartments PKG. TREATMENT PLT. C7 t y� �, _ �C; Method of,D�isp�os�al, Distance to nearest: We11��, Foundation c+ CJ~, v Property Line LEACHING LINE No. & Length of lines — �, � - - Total length/size FILTER BED ❑ Distance to nearest: Well foundation F Property Line I SEEPAGE PITS I I Depth F 7 Sire / �f X, r Number SUMPS r Il%�Distance to nearest: Well sF'�Foundation _Property Line�t�Q_F�� 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 regularions'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 peisori ih dtich,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 must call for alireqyrecl inspections. Complete drawing on reverse side. f p Signed X 4 Title: raZ�f� Oats: / ZZ FOR P . ENT.USE ONLY /gyp Application Accepted by Oaref v Pit or Grout inspection by Date j Final Inspection by Datt� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health'Scrvioes ._.,,..-,s,,. ,..,,.,.. _ .�-._•-•_-^---�x ��'' �-'°""'°'EnSliconment`al I{ea'lth'PerJmit/9ervices 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DAT PERMIT'NO. INFO . EH 11-21 tREV.ti`wsl /l EH 14,26 y