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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)458-3420 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 In made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. /r' // 2 Job Address 104So &• jPPleS7 RA City R `OMP Lot Size/Acreage-76' X '295' Owner's Name "'r iE k l y" + ,ATrres, _J ✓ r L I7 nr Phone 1323• '8(_'40 Contractor r+ �2�1LEAddress 7_50 Ave License No. 4/3q/8 Phone 923 -6Sl3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of service Well ❑ PUMP INSTALLATION D SYSTEM REPAIR ❑ OTHER C Monitoring well L7 DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f:l Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications I'I Public 1-1 Other 11 Delta Depth of Grout Seal Type of Grout t I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by _ }. Repair Work Done LJ Type of Pump __ H.P. State Work Done V r Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION Ite DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_V_ Commercial Other Number of living units: �_ Number of bedrooms ✓ Character of coif to a depth of 3 feet: i nke ." Water-table depth SEPTIC TANK ❑ Type/Mfg '1 _L Ca acit 1 �� P Y � � .._ No. Compartments r PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation ' /O Propeny Line LEACHING LINE No. & Length of lines s Total length/size FILTER BED n Distance to nearest: Well - Foundation Propeny-Line ^ SEEPAGE PITS I I Depth Size Number �/� SUMPS Itf, Distance to nearest: Well Foundation�1 � Property Line V' DISPOSAL PONDS ❑ 3^ `X 19 ' X f .S 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 t 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 pe ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." r The applicant must call for all required ins tions. Complete drawing on reverse side. / Signed X l°1'r't Title: / 2• " Date: OR DEPARTMENT USE ONLY Dat Application Accepted by + — 2 Z Z e Area � Pit or Grout Inspection by Date 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 O Box 2009, Stkn, CA 95201 - FEE 5201 -FEE AMOUNT DUE AMOUNT REMITTED CK If RECEIVED 9Y DYE PERMIT NO. INFO • EH 13-24[REV.Itstl EH 11.20 • [�~ / '+