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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 P PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ce, (Complete in Triplicate) t� UJC ' Application is hereby made to San Joaquin County for a permit to construct and/or insta Vh&A�1 ri( I �� fi�x,! �4r'f cribed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 an d"L i({j�dinle� d�jI �atI4—pyof San Joaquin County Public Health Services. `"''`Y•!!�� I�fj ��"PJr. ,, y Job Address ___ _ _• " _ City._,,„, Lot Size/Acreage5tOc-r0 a EO CA(. ddress $sax � 8 , ��24 3��too8 yE7-�3 Owner's Name �� 1A�oPhone ` Contractor S r~G C9to Addre s sAt �`^ ►� Z-� S License No._51 g� $ Phone IGS—Q-71 TYPE OF WELL/PUMP: NEW WELL C7 WELL REPLACEMENT ❑ DESTRUCTION AOut of Servibe Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK �� YJA --- SEWER LINES UO"DW DISPOSAL FLO. A/A PROP. LINE Ad FOUNDATION �_ AGRICULTURE WELL OTHER WELL]?_60/ PITS/SUMPS &JA ' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing Z� F1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications *C-H *0 f'I Public XO N I� Delta Depth of Grout Seal Type of Grout&5T 015M MMM Ii Irrigation pprox. Depth Eastern Surface Seal Installed by N- Repair Work Dane ❑ Type of Pump H.P. State Work Done Well Destruction Well Diameter Sealing Material & Depth ;L_-/4:-1 Depth ___ 7w ' Filler Material & Depth r-'6 TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 INo septic system permitted if publiclsewer is available within 200 feet.) Installation will serve: Residence^ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity Na. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line ti LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 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." The applicant m call for all require speetions. Co IpK drawing on reverse side, 1-955E AMW M 6-07S Signed Title: JZ- S� /F ! Date: .i FOR DEPARTMENT USE ONLYZZ3 ,J Application Accepted by Date /v Area Pit or Grout Inspection by Date ! Z3 nal Inspection b 49� Date j Additional Comments: epfi Applicant - Return all copies to: San Joaquin County Public Health Services 67 iA / Environmental Health Permit/Services Z L• [ { 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CIC 0 INFO / / ��\\ CASH RECEIV D BY DATE PERMIT'NO. :i . EH 13-31tREv.tiKSl W 66 �`�g�fy EH 11-2e ILLE�'EE If/ f/lJ6lr ` ✓i fJ 4 ilrk