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k t. ! SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (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. Job Address 2c?/ h'ed ee4y6idCity Ax Lot Size/Acreage �ef. -e / Address 2O "" Odlkehk XOwner's Name _,Z� hone /�� /� � `, q ^� / �7 Contractor �s �l`r Addr s�JOX�/�/ ��/`� g6 z�� -— L ic61 No. ��- Phone TYPE OF WELL/PUMP NEW WELL 0 WELL REPLACEMENT.Cl DESTRUCTION L1 Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER C] Monitoring Well o 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 Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f7 Domestic/Private D Gravel,Pack7 Ll Tracy Type of Casing_ Specifications I'I Public - her Cl Delta Depth of Grout Seal Type of Grout I I Irrigation � ?Approx. Depth, I I Eastern rSurface Seal Installed by e Repair Work Done 4Z. Type of Purrip d H.P. ��— State Work Done e Well Destruction ❑ Well Diameter Sealing Material & Depth Depth /6 b r Filler Material & Depth 7 OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I i INo septic system permitted if pub6r sewer r3 '"' a.� available within-200 lee" Installation will Residence_ Commercial___ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: ater table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Companments PKG, TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Property Line LEACHING LINE Ll No. & Lenl; s Total length FILTER BED ❑ ca to nearest: y Well Foundation Property Line SEEP�PlII Depth Sire ' 'Number SUMLI Distance to nearest: Well -Foundation Property Lina OSALPONDS ❑ 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 per$ manner as to become subject toworkman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the f owing: "I cc ify that in the pellormance ork for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws o Calif nia." The appl- nim t e r all re ra mplete rawing onr id ( Signed Title: s _ Date: 1 FO DEPARTMENT USE ONLY F Application Accepted by Date — Z Area 0 a Q� Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: F. Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CKECEIV BY ATE PERMIT NO. ` INFO CASHr ` rsi 53:24 IREV.,,M 5)