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A SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES `? ENVIRONMENTAL HEALTH DIVISION / 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 9520 , / 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. pp� Job Address " _ City Lot Size/Acreagel�Cr _— �,} r Owner's Name /'' Address Contractor ", s Address , f - License No. PhoneI ~ Z TYPE OF WELL/PUMP: NEW WELL� WELL REPLACEMENT ❑ DESTRUCTION 177 Out of Service Well ❑ PUMP INSTALLATIONX SYSTEM REPAIR C7 OTHER E) Monitors Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ""' PROP. LINE j � FOUNDATION AGRICULTURE WELL : OTHER WELL — PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT10.q5 f f L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ -� t Dia. of Well Casing Domestic/Private Cl Gravel Pack Pin Tracy Type of Casing_ Specifications f1 i'1 Public Ll Other n Delta Depth of Grout Seal 4b pe of Grout _ ,1 1 I IrriCation Approx. Depth l I Eastern Surface 5eaf Installed by Repair Work Done ❑ Type of Pump :L"VE ? H.P. _ State Work Done_ Well Destruction ❑ Well Diameter Sealinj} Material 6 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAtR/ADDITION I I DESTRUCTION I 1 lNo septic-system permitted if public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms �. Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation. Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well'. Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepar6d 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, t shall employ persons subject to workman's compensa- tion taws of California." _e ,-YTho applicant m t c ��/jjequirad ' i��Complete drawing on role"_side. Signad X ��iG'� ills: �Q `"_ Q-- Date: � �- F i tFOR DEPARTMENT USE _4(Y Application Accepter{ U Area �- Pit or rout Inapeetion by Date 1� Final Inspection by - Date Additional Commerttt � - Applicant - Return all copies to: San Joaquin County-Public-1MF1rtb-Services '- Environmental' Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK —RECEIVED BY DATE PERMWN0. INFO t _ CASH AcdaSL . EH 13.24 IREV.�i w I 51 _+ N EH 14.26 ��