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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 KL J af3 ZD-Z516-10 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. rgw q /3S8'7 N' c Zolr a µ � l�q3 NI .SiVtWc 57 �Prrt�►lottS Cdrt+�ril- /3977 1-p0) Lot Size/Acreage Jdb A'�dress'y - ZZ-7-1 ZZ Z ? ke City Owner's Namef/arLuGOYySM 5- O Address =0"I E+ S Phone Contractor f4_>,-Fe eAdress WZ " A, m License No. �Z7613 Phone 47yW—/3ys TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT C} DESTRUCTION ❑ Get Of- S"U'08-Veft—B PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. C1TgEL �v /0 FOUNDATION AGRICULTURE WELL OTHER WELL rr Ql KrE_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �*9/SI0 5eAAQ C1 Industrial O Open Bottom 0 Manteca Dia. of Well Excavation f:1 Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ .cpgai ratin�c 1'1 Public 1-1 Other Cl Delta Depth of Grout Seal .1MPe-ef wt >�F I i Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by � Repair Work Done 0 Type of Pump H.P. State Work Done �`� A ZA 6 I/ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer 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 No. Compartments \��1 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 1 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all ed inspections. Complete drawing on reverse side. �-7 Signed Title: /- t e6oL-(.rd-1S'� ---- Date: ! -30-9 Z _ FO DEP TMENT USE ONLY �7 Application Accepted by Date r � ` Area Pit or Grout Inspection by Date Final Inspection by ate 7-- Additional Comments. Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services [� 445 N Sea Joaquin, P O Box 2009, Stkn, CA 95201 _ r_, _,c•]_� FEE AMOUNT DUE AMOUNT REMITTED I CASH CEIV BY ATE PERMIT NO. INFO ,,� ✓� /}�J . EH13.2401EV.rrrSlSf v EH 14,2E