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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 EXPIRES 1 YEAR FROM DATE ISSUED I (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 ceonpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address �� 41—`r♦'.._ _. City SXG A� Lot Size/Acreage ` Owner's Name � Address �� Phone r Contractor /�'��/� Cwas' Address/�y I License No. 31 7?dr Phone 3l""V Z� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT>f DESTRUCTION t of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR C1 OTHER O Monitoring Well U I DISTANCE TO NEAREST: SEPTIC TANK/ SEWER LINES _ DISPOSAL FLD. L4 PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' -. � rr f �Ci_Industnal O Open Bottom_.__ ,O Manteca -Dia of Well Excavation Dia of Well Casing. Domestic/Private ;W Gravel Pack Ll Tracy Type ofrCasing__� r'r Specifications I'1 Public FI Other 1`7 Delta Depth of Grout Seal l e�7 Type of Grout _ �•�7 I I Irrigation 3'�t� Approx..Deptthl II Eastern Surface Seal Installed by 42k- y-S�etL \ f Repair Work Done L] Type of Pump t �• H P. 'Z __ State Work Done Well Destruction Well Diameter � Sealing Material at Depth 4 Depth1 W f Filler Material & Depth ' TYPE OF SEPTIC WORK: NEW INSTALLATION ['I REPAIR/ADDITION ! I DESTRUCTION € I INo septic system permitted if public sewer is i available within 200 feet. f Installation will serve: Residence — Commercial v Other Number-& living units: Number of bedrooms t.. Character of soil to a depth 1 60-felov Water table depth SEPTIC TANK O Type/Mfg' Capacity No. Compartments PKG. TREATMENT PLT. ❑ i f I Method of Disposal Distance to nearest: Well Foundation Property Line f I i I LEACHING LINE �L� No. & Length of lines _ _ Total length/size FILTER BED Cl ` Distance to nearest: Well Foundation Property Line SEEPAGE PITS .I 1 i Depth �_, Size - ` _� Number _ SUMPS .,LI Distance to nearest: Well Foundation Property Line ' y' DISPOSAL PONDS .' O 1 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 i Home owner or licensed agent's aignature.certifiett.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 com ensatiolaws of Oalifornia." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance o}the work for whic this permit rs issued,I shall imi!iloy persons subject to workman's corivensa tion taws of California.'; The applicant must call fr all I• puired inspections. Complete drawing on reverse side. Signed X / Title: a e.A '! Date. J., FOR DEPARTMENT USE ONLY t j; Application Accepted by ` Date ' Z-- Area o 4A Pit o Grout nspection by _ Date'�`�,�? Final Inspection by p e Date Additional Comments: U44 I Cw/ r4-010 Applicant - Re r a les t an oaquin oh y ubl Hea th 5 ry c / Environmental Health Permit/Servicest AAA �0 A 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 �l`Q �r �rRb FEE L g AMOUNT DUE AMOUNT REMITTED �K RECEIVED BY ATE PERMR NOiz') (� INFt i . fm 13-24(REV,r,M 51 I q 4L �� - r EH u-m t. t l _ -