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SAN rq'*')AQUIN COUNTY PUBLIC HEALTHRV I CESt 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 (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 Services. Job Address 20495 E. Walnut Drive City Li nden Lot Size/Acreage IS _ Owner's Name Dave Miller Address20475 E. Walnut Dr.Linden Phone 887-3687 Contractor Purviance DrillerskodTpip. P.O. Box 64 ,Lindenucense No.377923 Phone 887-3554 TYPE OF WELL/PUMP: NEW WELL Z WELL REPLACEMENT F DESTRUCTION o Out of Service Well ❑ PUMP INSTALLATION 91 SYSTEM REPAIR C] OTHER p Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 S Dia. of Well Casing 12 314 C] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Steel Specifications_. 1 RR I'I Public 11 Other fl Delta Depth of Grout Seal 300 Type of Grout Cement_.. 4: X-I Irrigation - 4U Approx. De th I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump ' H.P. 40 kF State Work Done_ e� Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I t Mo septic system permitted if public sewer is available within 200 feet.) Installation wile serve: Residence_ Commercial— Other Number of living units: Number of bed Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg I, a ' No. Compartments PKC. TREATMENT PLT. ❑ Per may 11ve MOTO fhn� p Method of Disposal Distance to nearest:WoWb �Omoun at re� INl r0 ertLine 1` + rrI LEACHING LINE ❑ No. & Length of lines fr i iylrQf if71l4l L1r�.r_ atal length/size FILTER BED I-] Distance to nearest: Well Foun ,. .dation��'gonProperty Line SEEPAGE PITS II Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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 Sen 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 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." Thet;� call for �nspecii.n. omplete drawing on reverse side. Signed Title: Corporate SecretaryDate: 7/5/93 1 ( R DEPARTMENT USE ONLY i Q Application Accepted by Date - t �2:�t Area ` ■��` r Pit or Grout Inspection by Date Final Inspection by 'Date 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 AMOUNT DUE AMOUNT REMITTED I CASH RECEIVED By DATE PERMIT'IVO. �tt. EH111.16ilf rVV 9.24(REV.I/As) EH /fr� lu& t 11-0