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+ t 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 lJoaquin 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 Services. 0ckes ie City (�AN� Lot Size/Acreage R' . Job Address /� r� s � Phone fi :2 7 4/6 Owner's Name CLIFF r ��e��Q�Address tea,3 !' �A(L6 L` 7'I.jt1 �U, ei e 62 License No. y3�� Phone cJ$7 Contractor-1�- Address WELL REPLACEM�J- 17 DESTRUCTION ❑ Out of Service Hell Cl TYPE OF WELL/PUMP: NEW WELL ❑ OTHER ❑ Monitoring well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 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 171 Industrial ' ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing C Domestic/Private ❑ Gra vet Pack 17 Tracy Type of Casing= Specifications -- - F7 Delta Depth of Grote Seal- I') Type of Grout I'1 Public I:1 Other ' t I Irrigation :Approx. Depth I 1 Eastern Surface Seal Installed by F 1. Repair Work Done L] Type of Pump H.P. State Work Done — . /,Well Destruction ❑ Well Diameter Sealing Material & DepthN- f� �)A "`q ..---Depth ------ Filler Material & Depth F �y �� TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l DESTRUCTION I'I ]No septic system permitted it public sewer is available within 200 1eet.l,� serve: Residence_V_ Commerciale Other installatiori-wid Number of fiving nits:'^1 Number of bedrooms Character of soil to a depth of 3 fi-ev— Water:.tabfe depth SEPTIC TANK ❑ Type/Mfg 1 Capacity ' No. Compartments ^- Method of Disposal PKG. TREATMENT PLY. ❑ 110... Distance to nearest:-Welt— Foundation- Property Line LEACHING LINE No. & Length of lines yTo I`leng[h/size FILTER BED n Distance to nearest: el _1�0� Foundation 'ropany Line' ti SEEPAGE PITS 11 Depth Size " Number /i - SUMPS L! Dstance to nearest: Well Fou to Property Line DISPOSAL PONDS ❑ I i . ./ ifl b- A o A i ►611AI G 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 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 I 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 lawjof California." The applicant must tail for all req- ed�'s tions. Complete drawing on,reverse side. l Signed X Title: L - Date: F R DEPARTMEf T USE ONLY Application Accepted by ata DArea � Pit or Grout Inspection by Date Final Inspection b C Dattr� f Additional Comments: a Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services ' . ---r-445-N-San--Joaquin•r.�-P-O--Box<2009�Stkn--GA-95201 FEE AMOUNT DUE`S AMOUNT REMITTED CK RECEIVED BY ATE PERMIT'NO. INFO • EH 13.211/iEV. EH 14-20