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JOAQUIN COUNTY PUBLIC HEALTH SERVICES �., ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 t 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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Sery cee. City �r�N[ow Lot Size/Acreage �S !![Job Address --�— 1 7r Address Phone Owner's Name U/„ /� _ _ _ _ r it��.in 91101" A00A License No. Conhactor TYPE OF WELL/PUMP: NEW WELL CJ WELL REP AGEMENT Cl DESTRUCTION Out of Service Weil ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK ' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION f AGRICULTURE WELL OTHER WELL PITSISUMPS Phone r� INTENDED USE n Industrial Cl Domestic/ Private it Public I I Irrigation Repair Wor� Done 0 Weil Destruction ❑ PE OF SE TYPE OF WELL PROBLEM AREA CONSTRUG 11Uty jrtC.1r1%f+ I Mv040 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Cl Other n Delta Depth of Grout Seal Type of Grout Approx. Depth I I Eastern Surface Seal Installed by Type of Pump i H. P. State Work Done Well Diameter Sealing Material is Depth Depth I Filler Material A Depth K; NEW INSTALLATION I 1 REPAIR/ Installation will serve: Residence __ Commercial Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ Type/Mfg f PKG. TREATMENT PLT. ❑ Distance to nearest: F LEACHING LINE ❑ No. & Length of lines FILTER BED ❑ Distance to rnearest. Well Other TION I I I INo septic system permitted i1 public sewer 1s available within 200 feet.! Water table depth _,._ Capacity No. Compartments Method of Disposal dation Property Line Total length/size Property Line SEEPAGE PITS I I Depth zeNumber 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 San Joaquin County Home owner or licensed agent's signature certifies the following: "I cartify 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." The applicant m t all for all req . ed inspecti . C late dr ing on reverse side. Signed K Title: , _ Date: FORD1 PARTMENT USE ONLY Application Accepted by Pit or Grout Inspection by Additional Comments. t 1 Applicant - Return all copies to FEE I AMOUNT DUE INFO + EH 13-24IREV.I/h51 EK a-26 V Date — ,+ �. rea Data Final Inspection by Date%� San Joaquin County Public health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 AMOUNT REMITTED rCecu RECEIVED BY DATE IIW�IRmr R PERMIT, w. _,_ Z 1*