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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 445 'ENVIRONMENTAL AN 0PHONE (209)468-3420 HEALTH P 0 BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 1 YEAR FROM DATE ISSUED lt2 ,. y,E ,pj (Complete in Triplicate) Application is hereby made to San Joaquin County fore I!J3-' a3" -49/ application ie made in coHPlianceivith San Joaquin countyrp dinancenNoru549$andnd/o1862eeRuworkles andeRegulationsdof Sans Joaquin County Public Health Services. and the f Job Address i I qtY Lot Size/Acreage Igo Owner's Name e o n CL/L rL Y L [ Z Address 14629 11 t Qt l j Phone ContractorC&Ak GIP. U Address License No.�Phone TYPE Of WELL/PUMP: NEW WELL p WELL REPLACEMENT ❑ ! PUMP INSTALLATION ❑ DES TRUC T[UN Cl Out of Service well ❑ ' SYSTEM REPAIRrVX OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1 f.7 Domestic/Private L-1 Gravel Tracy Type of Casing_ Gravel Pack Dia. of Well Casing I'i Public f:7 Other 11 Delta Specifications Depth of Grout Seal Type of Grout I ! Irrigation _Approx. Depth I I Eastern Repair Work pane U T' � Surface Seat Installed by the of Pump it n 0. :„e H,P. _ Well Destruction ❑ Well Diameter Sealing Material Depth State Work Done Depth j Filler Material i Depth Onn e c t L pn TYPE OF SEPTIC WORK; NEW INSTALLATION i I REPAIRlADDITiON I 1 DESTRUCTION I ! iNo septic system permitted if public sewer is Installation will serve: Residence•_..� Commercial available within 200 feet.l Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: I SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ❑ Capacity No. Compartments Distance to nIarest: Well Method of Disposal Foundation Property Line �j LEACHING LINE C1No. & Length of lines FILTER BED- i Total length/size ❑ Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth —Size SUMPS Number Li Distance to nearest: Well Foundation DISPOSAL PONDS C] Property Line :97 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 Horne 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 g m : "I cert"such manner as to beco certifies the following: subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature t rformence of the work for which this permit is issued, I shall employ tion Iowa of Caii orni p y persons subject to workman's compensa- tion applican all r r i d ! ions. Complete drawing on reverse side. Signed Title: vl Cia�tk Glee-e Data: 2 7 Oc,f. 92 Mj=-USE ONLY - Application Accepted by Area�� Pit or Grout inspection by AA Date Date it ` # —."-��. Final Inspection by Date 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 AMOUNT DUE AMOUNT REMITTED MFgnj INFO �y ;DATE PERMIT'N0. EM 13-2I(REV.t/KSi W� -f .�tEFt t4•2a