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AMYL11:A114JJN SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �j ENVIRONMENTAL HEALTH DIVISION o y� .445 N SAN JOAQUIN, PHONE (209)468 3420 61- J�a P O BOX 2009j STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (COmplete ,-til,Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This 4"Itea'tibn to made in compliance with Sen Joaquin County Ordinance No. 549 and 1862 and the Rules and nopumtso"o tai' Isno Joaquin County Public cHealth 8ery o/e/e.�y`�l � / f t Job Address �/ �� ver �1 /'��C/�il l IlL//L/,i / of Size/Acreage ANW3— .�. _ . Owner's Name (,�[L /1 �(�i-/lLJ Address �tG�-ter✓ !✓ dw Phone o t ' 0 ��iY se No. hone / TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTIV 0,96t of Service Well PUMP INSTALLATIO',� SYSTEM REPAIR ❑ OTHER Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK /17/1 L SEWER LINES167 DISPOSAL FLD. PROP. LINE t FOUNDATION .--. -- AGRICULTURE WELL OTHER WELL PITS($WMPS `r INTENDED USE JNPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial n Bottom ❑ Manteca Dia. of We11 Excavation Dia. of Well Casing// Cl Domestic/Private / vel Pack ❑ Trac Type of Casing_ t Specifications cifications � V Yp 9 5-1J I'1 noblic El Other 1-1 Delta Depth of Grout SealType of, I Igation Approx. Depth I I Eastern Surface Soul Installed by Repair Work Done U T of Pum H.P. State Work Done Type P _ Well Destruction ❑ Well Diameter Sealing Material & Depth ^ Depth Filler Material & Depth _f wk_ .i9�-,n ow TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I I DESTRUCTION I 1 INo septic system permitted if public r 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: }` Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify that 1 have prepared this application iind 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, 1 shall not employ any person in such manner as to become subject to workman's,compensation laws of Califor ia.-Contractor's hiring or subcontracting signature certifies the following: "I certify th the pert the work for which this permit is issued half employ arsons ubject to workman's compenaa tion laws of California.' / � X V. The applic Yat cam s C s. C I e wing on rover side. SipZVTitle: Data. 1 FOR DEPARTMENT USE ONLY C Application Accepted by bate 1-�' 1 2- Area_ l /ter ' y Pit o "dr by f � Date y�^' Final Inspection by Date L 3 Additional Comments: Applicant - Return all copies t0: San Joaquin dountq Public Health Services — Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 G 7" CK 41 0� / l ttGQJf sraCoo' JNA DUN T DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. nom/ s • EH 13.24 IREV.1/HS) W C�-}s,� d -7 /� "1� �.J-'s G� `�V� �}t,✓{nfGl///�J"w EH 114-M ..- L(A �� Y?l> [, ✓_ /' !r'/ /ti/ fy qa-6�� -