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SAN JOAQUIN COUNTY PUBLIC IC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-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. lez ✓Job Address /rl City --S;q& Lot Size/Acreage 1,-'Owner's Name %7,it-wvz� AG40 Address _ Z2 Z—/k _ �llc Phone sl�J ✓ � OF Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT CJ DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER p Monitoring Well CJ j DISTANCE TO NEAREST: SEPTIC TANK } SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS P Industrial ❑ Open Bottom �, ❑ Manteca Dia. of Well Excavation Dia. of Well Casing F] Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing_ Specifications 1'I Public CI Other hl Delta Depth of Grout Seal! type of Grout I i Irrigation —Approx.-Depth I 1 Eastern Surface Seal lnstallad by 4 Repair Work Done LJ Type of-Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth- Filler Material & Depth n? TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION 1 DESTRUCTION I ! Mo septic system permitted if public sewer is j " o ? i / available within 200 feet.l Installation will serve: Residence_.._ Commercial_ Other - N mu ber of living units: / � Number of bedrooms Character of soil to a depth of 3 feet":- Water table depth SEPTIC TANKType/Mf Z 9 Capacity No. Compartments 1 J I PKG. TREATMENT PLT. ❑ ^ CC Method of Disposal Distance to nearest: Well c�� Foundation Property Line LEACHING LINE 0--No. & Length of lines 4 aTgtal length/size FILTER BED ❑ Distance to nearest. Well Foundation --/J — Property Line SEEPAGE PITS Depth Size Number SUMPS - r. Ll Distance to nearest: Well tion Property Line DISPOSAL PONDS ❑ lbot 3 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 CountyIx - - ; Home owner or licensed agent's' certifies the following: "I cartify`that in the performance of-the-work`iar which.this permit is issued, I sliall.not�. employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring ofsutf 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 w The applica call fo;i all requir spe Complete drawing on reverse side. Signed X Title: J Date: / 2 FOR DEPARTMENT USE ONLY �A Application Accepted by {{ G r Date i 7 !� -!yArea Pit or Grout Inspection by Date Final Inspection,by Dais µ AdditionalComrnenta: r Applicant - R u!n 'a cop iJA1-%lRftWS-akn JoaInoun lthqY u c Health vices Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 q. FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. INFO CASH e . EH 13-N TREY.I,/n SI 613 . EH Tae f L `f�]�y y