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K= SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P -O BOX 2009 STOCKTON, CA 95201 A $ 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 trade in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services..' �1Job Address ' f City `J �� hot Size/Acreage g,-2 'a YII Owner's Name Address Phone ontractar d rens License No. Phon TYPE OF WELL/PUMP: NEW WELL CO WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well LI SYSTEM REPAIR C] p R M toring Well C7 PUMP INSTALLATION ❑ (A DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PR P. L N FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE n industrial [] Domestic/ Private f'1 Public I I irrigation Repair Work Done Well Destruction TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom. 111 Manteca Dia. of Well Excavation ❑ Gravel Pack ❑ Tracy Type of Casing_ ;_.1 Other F1 Delta Depth of Grout Seal --_40-,, Aepprox. Depth I I Eastern Surface Seal Installed by I] Type of Pump H. P. State Work Done . i Sealing Material & Depth ❑ Well Diameter LI rSeeth _- f rFiller Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REP/ installation will serve: Residence — Commercial . Number of living units: Numberr of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK. 1 ❑ Type/Mfg i PKG. TREATMENT PLT. ❑ Distance to nearest: Well ADDITION I ! Foundation Dia. of Well Casing Specifications Type of Grout ON I I iNo septic system permul available within 200 feet.) Water table depth - _ No. Compartments Method of Disposal Property Line public sewer is LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED CI Distance to nearest. Welt I Foundation Property Line SEEPAGE PITS 11 Deptha Numbs SUMPS LI Distance to nearest: Well Foundation Pro rty Line 1 r)ISPOSAL PONDS El 1 _ 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 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." I The applica ust call fo all required in" ons. Co late drawing oNZLZ 2j YSigned • Title: �Date: Application Accepted by Pit or Grout Inspection Add * a krna ADDlicant - . EM 13-241REV. I/"5 EH 14.28 ENT USE ONLY fir+ Date � Area Final Inspection by m w,.• ii i c -'-V - s oto: San Joaquin County Public Health Services Environmental Health Permit/Uervices 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 Data FEE INFO AMOUNT DUE k AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMI�NO�, 0 OD!] � �iQ t� (] 197 o,� R�