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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 i PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) Application is hereby made,to Sen Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joa in County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin C Public Health :48 Job Address Ci Lot Size/Acreage wner's Nar�+��t i X NV LL IU Address Phone` ct r reSr' o. I Phone v TYPE OF WELL/PUMP: NEW WELL C3 WELL REPLACEMENT (] DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATI01 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well O DISTANCE TO NEAREST; SEPTIC TANK / SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ' I INTENDED USE, TYPE OF WELL PROBLEM AREA! CONSTRUCTION SPECIFICATIONS 1 du-trial f ❑ Open Bottom 171 Manteca t Dia. of Well Excavation Dia. of Well Casing isticlPrivate� Eli 1 ❑ Gravel Pack Tracy Type of Casing_ Specifications I' I P,itilic' (., Other 171 Delta Depth of Grout Seal T f Grout I I InigaN6n j _..Approx.;pe l I Eastern `6urface Seal Installed by Repair Wprk Done L7 I Type-of-_PUMP. +jam H;P. State Work Do Well Destruction ❑ Well Diameter F f $soling Material & Depth Depth ! Filler Material & Depth TYPE OF'SEPTIC WORK; NEW INSTALLATION I ] REPAIR/ADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is available within 204 feet.l Installation will serve: Residence Commercial_ Other Number of living units: 1 Number of bedrooms \ Character--of_soil_to-a,depthlof 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg r Capacity Na. Compartments PKG. TREATMENT PLT.❑ Method of Disposal 4 Distance to nearest Well Foundation Property Line LEACHING LINE ❑ No, & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth 1 Size Number ~ SUMPS Ll Distance to nearest: Well �: !Foundation Property Line DISPOSAL PONDS ❑ I r4 , I hereby certify that I have prepared this application and that the work will�bedone in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County ' 1 Home owner or licensed agent's signature certifies the following; "I certify that ih.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,.1 shall employ persons subject to workman's compensa- tion laws of California.' 4 The applica st call for I required intpections. Complete drawing on re e side. /� I Signe Title: Date: R DEPARTMENT USE ONLY z v k Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Data Additional Comments: i Applicant - Return all copies! to: San Joaquin County Public Health Services Environmental Health Permit/Services Ile 445 N San Joaquin, Box 2009, Stkn, CA 95201 IF E AMOUNT DUE AMOUNT REMITTED f CAS CK If REC VED BY ATE PERMIT'NO, i + EN 13.21(REV. EH 11-2E i ! � y t k