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i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 4 II3VIRONMFsNTAL HEALTH DIVISION 445 N SAN �10AQUIN, PHONE (209)468-3420 p 0 BOX 2009, STOCETON, CA gg20� PERMIT EXPIRES 1 YEAR FROM DATE ISSUID (Complete in Triplicate) permit to construct and/or install the cork herein described. This for a p Regulations of San Application is hereby made to San Joaquin Sa County Ordinance No. 549 and 1862 and the Rules and application is made in compliance with San Joaquin County Joaquln County Public Health Services. r�' Lot Size/Acreage O La�N� City -7 Job Address � Phone + �A.r 2 Address S FqeAC; 7 Owner's Name �c' phone PUMP INSTALLATION N � License No Out of Service Well ❑ Address DESTRUCTION O Well Cont+actor WELL REPLACEMENT ❑ OTHER ❑ Monitoring ❑ NEW WELL 0 r TYPE C WELt/PUMP. SYSTEM REPAIR ❑ PROP. LINE j ` � DISPOSAL FLq.�-- DISTANCE 70 NEAREST: SEPTIC TANK p175lSUMPS _..--- (vj� SEWER LINES —r-�' OTHER WELL�---- r-- AGRICULTURE WELL FOUNDATION ��---- TYPE OF WELL PAOBL� EM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing INTENDED USE p Manteca Dia. of Well Excavation Specifications ❑ Open Bottom C1 Industrial �] Tracy Type of Casing_ Type of Grout (►�mesticlPrivate Ll Gravel Pack Depth of Grout Seal n Delta (:1 Other I'i Public Surface Seal Installed by i I IrrigationK.P.APprox. Depth 1 I Eastern State Work Done I Repair Work Done U Type of Pump _Sealing Material & Depth Well Destruction ❑ Weil Diameter �--� /� Filler Materiel & DePth j Depthper- O f available within 200 feet.) TYPE Of SEPTIC WORK: NEW 1NSTALl11TION I I REPAIRlADOITION { I DESTRUCTION I I' lNo septic within 2 0feettted it public sewer Other GOfT mefCial .�----� Installation will serve: Residence r e n Number of living units: Number of bedrooms --- ` "" T Water table depth Character of soil to a depth of 3 feet: Capacity— No. Compartments i SEPTIC TANK O Type/Mfg Method of Disposal PKG. TREATMENT PLT. ❑ Foundation�— property Line--�� Distance to nearest: Well t t Total tengthlsize LEACHING LINE 0 No. & Length of lines property Line - r ❑ Distance to nearest. Well Foundation �-- FILTER BED Number } SEEPAGE PITS l I Depth Size Property Line SUMPS ____---- LI Distance to nearest: Well��— Foundation 11., .t ,f r DISPOSAL PONDS ❑ . . . ` .. - ip. . .... ..- 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 shall not rules and regulations of the San Joaquin County following: work for Home owner r licensed signature to b cwomfies the e subjects to workman'srtcompensation laws California."Contractowhich s1hiri gr or sub-contracs permit is t ngls signature employ any person in such certifies the following: "1 certify that in the performance of the work for which this permit is issued, l shall employ parsons subject to workman's compen Non laws of California." The applicant must call for all required inspections. Complete drawing on reverse 'de. ' Title: Date: � Signed X -- FOR.DEPARTMENT USE ONLY Date Are' Application Accepted by Date Pit or Grout Inspection by t Date�-- Final Inspection by k Additional Comments Applicant - Return all CopiBs to: Enviroamentalan joaquin nHealth unty uPermit/services blic Health vices 445 N•San Joaquin, P O Box 2009, Stkn, CA 95201 1 � �~ CK ECEIVED BY 0 TE PERMIT'N0, 1111 FEE AM t}NT DUE AMOUNT REMITTED IN 0 AA . EK13.24(REV.��ns� 10 EH 14.26 i