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,.SAN %_,AQUIN COUNTY PUBLIC HEALTH CkVICES r I , - ENVIRONMENTAL HEALTH DIVISION 445 'Y SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT MIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereapc by made to San Joaquin Count; for a permit to construct and/or in t wo her t1yed. This application is made in compliance with San Joaquil,County Ordinance No. 51+9 and 1862 anddthh l an ti8ne of San Joaquin County Public Health Services. y Job Address S3 " � City Lot Size/Acreage Owner's Name �ig��2� Address Phone Contractor Address ._ �2 License No. d Phon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLA MENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 171OTHER ❑ Monitoring Well ❑ 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 SPECIFICATttNS Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation T Dia. of Well Casing 3 C.1 DomestielPrivate ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications - CI Public 1-1-Other 11 Delta Depth of Grout Seal Type of Grout 11 Irrigation Approx, Depth l I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction ❑ Welt Diameter Sealing Material i Depth Filler Material i Depth Depth ` li i TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION l I (No septic system pvmitted if public sewer is 1 available within 200 fiat.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms +1 Character of soil to a depth of 3 feet: Water table depth :. I SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal - Distance to nearest: Well Foundation Property line - LEACHING LINE ❑ No. & Length of lines "" eL Total length/size , FILTER BED ❑ Distance to nearest: Watt Foundations Property Line SEEPAGE PITS 11 Depth Site _ `per- _ Number SUMPS 0 Distance to nearest: :Well Foundation / Property Line _ DISPOSAL PONDS ❑ I hereby certify that t 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 of licensed agent's signature certifies the following: "I certify 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 all for all to +r nspeeti s. Complete drawing on reverse side. } Date: { `� Signed X Title: FOR DEPARTMENT USE ONLY l Application Accepted by r Date _ CJ_l �� Area M &or Grout Inspection by ate r r� Final Inspection by T-�� ;// Date �2 Additional Comments: Applicant - Return all copies to: San Joagqin County Public Health Services Environmental Health Permit/Services 1 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17-NO. i INFO . EH :24saEv.,,Ks+t5� /y Z/ 7_Z- EH 1,-26 j ,