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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES € I ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P 0 BOX 2009, STOCKTON, CA 9520 . a 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 1662 and the Rules and Regulations of San Joaquin County Public Health Services. r Job Address Q I 0 City Lot Size/Acreage Cs7a) Owner's Name Cd e e I Address 1 to55 W ic,�S D+ i/ rJaYt �'AHr�t�hone X63 l>A'r ��' SCS � — Contractor RE�SKtA - _ I_-Address 505 SIA VL56rtle_ 5.1r. License No.6Z9716o Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION Xbut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C1 Domestic/Private Gl Gravel Pack! ❑ Tracy Type of Casing_54-e.e, Specifications I'1 Public El Other � n Delta Depth of Grout Seal Type of Grout I # Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L] Type of Pump A,11-4- H.P. State Work Done _ +t Sealing Material & Depth t)n A^*w n Well Destruction X Well Diameter 0 r Filler Material & Depth U e .t3 P Depth �{ to �. wrn -TYPE OF OF SEPTIC WORK: NEW INSTALLATION I I REPAIRJADDITION I I DESTRUCTION I I iNo septic system permitted it public sewer is Q 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: i Water table depth SEPTIC TANK ❑ Type/Mfg + Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to Larest: Well Foundation Property Line a LEACHING LINE CI No. & Length of lines Total length/size E FILTER BED ❑ Distance to'nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number I SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl I hereby certify that t 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�csnifies 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." I The applicant must call for all required insPections. Complete drawing on reverse side. Signed Title: 'Pr-0 1 Q-.c—+_ r 1 l!5 i r,e_V_r Date: OR DEPARTMENT USE ONLY Application Accepted by + Date V,Vev Pit or Grout Inspection by IDate Final Inspoption by Dat Additional Comments: Applicant - Return all copies+ to: San Joaquin County Public Health Services I Environmental Health Permit/Services 445 N San Joaquin, P O Box 2049, Stkn, CA 95201FEE INFO AMOUNT DUE f AMOUNT CASH CASH RECEFVED BY DATE PERMIT'N0. Eft 13.24(REV.riKsi �0 t EH 14-Z0 / 0/,0J,