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` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 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 1862 and the Rules and Regulations of San Joaquin County /v 1 Public/Health Services. Job Address lam!- � A r 0 1`a e City 4Air Lot Size/Acreage Owner's Name _I a I L�U��S Address I� � �' /4621 n Phone I Contractor (' ra r Lot, �U Address fC�C� �_ Va uCLicense No. vb gS1 Phone ��Wq TYPE OF WELL/PUMP: NEW WELL $k WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION$- SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 100 1 SEWER LINES 1001 fi DISPOSAL FLD. PROP. LINE 20 1 FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMPS INOI INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation if Dia. of Well Casing (p (Domestic/Private [F-Gravel Pack ❑ Tracy Type of Casing_ SRe— SLpecifications I'1 Public Cl Othe; n Delta Depth of Grout Seal "<-191160' "Type of Grout :�'i-'�- _ 611 I I Irrigation vApprox. Depth""��I��I�Eastern Surface Seal Installed by th/ Repair Work Done U Type of Pump 4l1M H.P. ( I/Z State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it 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 0 . Type-/Mfg_ Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & 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 ❑ 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, I shall employ persons subject to workman's compensa- tion laws of California." The applicem s call for all required ins f, ns. Complet yawing on reverse side. Signed X + — �`�'s'' Title: ��J1__�d ( , Date: lI7—q3 FO EPARTMENT USE ONLY Application Accepted by Date Area K. C`\- Pit or G ut' spection by Date Final Inspection by Date3 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUEAMOUNT REMITTED CASH CK 0 RECEIVED BY DATE PERMIT'N0. . EH13.24(REV.1/x 5) 2 �b (� ^/" 17JI EH 114.21 G..,