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PERMIT E;OAQUIN D APPLICATION �000 COUNTY PUBLIC HEALTH S Permit may have expired without ENVIRONMENTAL HEALTH DIVISI0 work beingcompleted or ins�R06 JOAQUIN, PHONE (209)46 P BOX 2009, STOCKTON, CA 95 by Environmental Health Division PERMIT EXPIRES 1 YEAR FROM DATESITEn (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork stein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. � So Job Address _ / (/� QL y� / '^' � �T� City ��'/Lot Size/Acreage Owner's Name �jC�i(% Or/',�djr"e5' �( �p CS ' /% r Phone It Contractor _= ��—�— Address ,& License No. _ Phone !�7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 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 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia. of Well Casing r7 Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I.1 Public 1-1 Other I-1 Delta Depth of Grout Seal — Type of Grout I I ImUdtion __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 11 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION ' I REPAIR/ADDITION i I DESTRUCTION(No septic system permitted if public sewer is available within 200 feet.) 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 Pr cPAV LEACHING LINE ❑ No. b Length of lines Total lanpit FILTER BED ❑ Distance to nearest: Well Foundation PJAty2ir5 SEEPAGE PITS 11 Depth Size _ Oki LINTY SUMPS LI Distance to nearest: Well FoundationEN �,fl�$— DISPOSAL PONDS ❑ Pq Ilk oma, Co —, rear r have waparud this appucauon 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 cenifies the fonowing: "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 appli m st call for all requri ' spections. Complete drawing on reverse side. Signed �� / J Title: // Date: FOR DEPARTMENT USE ONLY Application Accepted by _Date 1 2_ Area Pit or Grout Inspection by (� A Date j� (Final Inspec ion,byy Date Additional Comments: � �, i( JCCayL— Applicant - Return all copies toV San Joaquin County PublicViealth Servius Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 ( j �(E�/nsr FEE gMOUNT DUE AMOUNT REMITTED K RECEIVED BYyINFO 'j�C,�Aq H DATEEH 102 L -7L SX �' — IL aocb FH 142e t I!I / V