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SAN JOAQUIN COURTY "PUBLIC HEALTH SERVICES I ENVIRONMENTAL REALTH DIVISION 445•N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 } wl P /�Q Poti PERMIT EXPIRES 1 YEAR FROM DATE I S SUED " (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 1$62 andt e I�les,e<nd Regulations of San t Joaquin County Public Health Services. riG/Osr ©P, _ ( Z r Job AddressCityr._.i . Lot Size/Acreage 7 7 Ae- Owner's Name d -+ Address 6 Phone Coniractorf�� ver 5- Address� 7 -,r.,�1�� P� License No.��?oya_ Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll Out of Service Well PUMP INSTALLATION O SYSTEM REPAIR OTHER C3 Monitoring Well C] 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 f-! Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing C:1 Domestic/Private ❑ Gravel Pack - CI-Tracy =" _ -- Type-of Casing_ Specifications _ I'1 Public 1-1 Other n Delta Depth of Grout Seal Type of Grout Irrigation —..Approx. Dh I�Eastern Surface Seal Installed by Repair Work Done e& Type of Pump, 16h ll�bcgj.e H.P. <1C State Work Done c> j Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material:& Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I J DESTRUCTION I i INo septic system permitted if public sewer is l available within 200 feet.) Installation will serve: Residence— Commercial_ Other Number of living units: 1 Number of bedrooms f Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK ❑ Type/Mfg Cap acity -No. Compartments PKG, TREATMENT PLT. I;) i' Method of Disposal{ Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No.'B Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS It Depth Size _ Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS fJ 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 s" i 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'Cafiforniaa Contractor's hiring of 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 mpsnsa- tion laws of California." i; The a ' ant mus all for all requ" ins pe ons. Complete drawing on side. ,_ 09Signed X Title: S Date: 357- u OR DEPARTMENT USE ONLY Application Accepted by ��wv; +1•�11� Date Z Area Pit or Grout Inspection by I Date Final Inspection by Date Additional Comments: ---- . Y---� .. ------ - - -- - - Applicant - Return all copies to: San Joaquin County Public health Services Environmental Health Permit/Services 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT•NO. Q[� � 00 ) . EN i3.241AINFO EY. /NS1 f�V EH t4.2e pS I ✓ •r _' i