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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT FIRES 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 Se"i ea. Job Address �-`_Vr� `_� ' r1/n' 1`^^• City Lot Size/Acreage (994weli CLtAQAD Owner's Name (1! �1/ Address Phone w -?67 Contract Address a OL-L'GLS-•_ License No.�2�Z ZOO Phone TYPE OF WELL/PUMP, NEW WELL ❑ WELL REPLACEMENT Ll DESTRUCTION ❑ Out of S PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ N FOUNDATION AGRICULTURE WELL OTHER WELL ..PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications FI Public fa Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx, Depth 1 1 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done._ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Piller Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I IREPAIR ADDITION DESTRUCTION I I (No septic system permitted if public sewer a available within 200 feet.) Installation will serve: Re idents_ Commercial_ Other Number of living units: Number of bed . s �D Character of Boit to a depth of 3 feet: Water table depth SEPTIC TANK Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. i Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line z Ir SEEPAGE PITS Depth Size NYmber z SUMPS LI Distance to nearest: Well IC)O Foundation 0 Property Line S 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 regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "I canify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or subcontracting 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." The applicant st call fo re ed Inspections. Complete drawing on reverseaidP, `(�r�' ny Signed X Title: , fv Date: / FOR DEPARTMENT USE ONLY �� 12 Application Accepted by - Data � � 2 Z Araa �• _ n H r Grout Impaction by Inspection by � Date2, i2 Additional Comments: 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 FEE NFO AMOUNT DUE AMOUNT REMITTED CK ECEIVED BY DATE PERMIT NO. . EN 17-2s(REV-Ila or O EH t�26 O