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Y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 �b PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j (Complete in Triplicate) Application Is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This I 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. ' !I Job Address 3 2 3 7 h 2 City,U k n Lot Size/Acreage 9 f 1 Q Cen.tuny 21 Exchan9� 6011 N. E.e Don.ado 951 -2995 Owner's Name Address Phone Contractor Ua zk Gle te, Inc Address 2024 C. Cha2-f-en License N0.3 7 15 b 0 phone " 462-76Z6 w TYPE Of WELL/PUMP: NEW WELL Q WELL REPLACEMENTS DESTRUCTIONV0 Out of Service Well 0 ' PUMP INSTALLATION >>S X SYSTEM REPAIR Cl OTHER ❑ Monitoring Well L1 DISTANCE TO NEAREST: SEPTIC TANK 5 5 ' SEWER LINES DISPOSAL FLD. PROP. LINT !, FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS -LD 0' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " n Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation _- _17" Dia. of Well Casing 4kRomestic/Private XXM-'iravel Pack C7 Tracy Type of Casing.2 VC Specifications IEj---- I'l Public fa Otper 171 Delta Depth of Grout Seal -1 0 0= Type of Grout-9 . An r k I I Irrigation V Approx. Depth I I Eastern Surface Seal Installed by Ua zk { t t Repair Work Done 0 . Type of Pump SUL H.P. .1 ? State Work Done 11,611 Well Destruction Well Diameter 6' Sealing Material & Depth 9 0 D DepthC�l�R 120 Filler Material & Depth �.�L y � cV-m2n TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is 4 available within 200 feet.) !1 Installation will serve: Residence_ Commercial T Other "Number of living units: Number of bedrooms ll. Character of soil to a depth of 3 feet: Water tabie-depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal54 ti 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 Size Number SUMPS El 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 Calilornia." Contractor's hiring or sub-contracting signature certifies the following: "I ce the rtormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California " The applicant t r I it ms ns. om ete drawing on reverse side. 4 Signed Title:I {CL;-A4 644,9, I Data: 27 O c.t 92 FOR DEPARTMENT USE ONLY d �fjJ Application Accepted by Date �'Z 7-! Z Area __��/ ��• ' Pit or Grou Inspection by ._Date � +� Final Inspection by Data Additional Comments: Vkj I&Z& l/ E r ' Applicant - Return all copies to: San Joaquin County Public Health Services �� (� b Environmental Health Permit/Services �! { 445 N San Joaquin, P 0 Box 2009, Stkn, CA 9520`-<,L 5201 7 ,.ed?t;W FEE INFO AMOUNT DUE - AMOUNT REMITTED A RECEIVED BY DATE PERM]T NO. + EH13.24(REV. 51 EH 114.2E / `, U/ 9� a5-P6