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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 trade 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 Public Health Services. Job Address Citys Lot Size/Acreage tA5 Acus Ifo Phone I 6— 3 Owner's Name MAS ZdA CAD l Address p� Contfactor Bagh AID, Address License NAeZZ 3 a Phone)- tt 5 TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT n DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERnit i ell s d'E 2.5 DISTANCE TO NEAREST: SEPTIC TANK y/IA - SEWER LINES 5� DISPOSAL FLD.� PROP. LINE FOUNDATION L AGRICULTURE WELL _bJ&_ OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS If CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack Ll Tracy Type of Casing- I'VG Specifications o�ti I'i Public Xother XDalta Depth of Grout Seal 1.s _ Type of Grout I I Irrigation —.Approx. Depth i•I Eastern Surface Seal Installed by A DR Repair Work Done 0 Type of Pump H.P, State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth T I N t' tern permitted if public sewer is TYPE OF SEPTIC WORK: NEW INSTALLATION ! I REPAIR/ADDITION I I DESTRUCTION I I a septic sys p p available within 200 feet.) N1 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. ❑ A Method��oof�Dii�sp�osal iria4AEN Distance to nearest: Well Foundation Prop T LEACHING LINE 'yA ❑ No. & Length of lines Total length i FILTER BED ❑ Distance to nearest: Well Foundation Pro in 912 Sipm -JOAQUIN COU Y. SEEPAGE PITS N/A i I Depth Size NumlagUBLIC HEALTHIt✓ � SUMPS CI Distance to nearest: Well Foundation— DISPOSAL oundation DISPOSAL PONDS ❑ 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 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 applicant ust call for II r quirad in psctions. Complete drawing on reverse side. q Signed X Title; nl P-� "ted I .� Date: FOR DEPARTMENT USE ONLY Application Accepted by Date �� Area r _ Pit or Grout Inspection by a ate `' Final Inspection by" V ' ' tl 1 Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services / Environmental Health Permit/Services n IV ��y( 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 OY I IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. Q 1h . EH 13-24 IAEV,I/As) L-T— +l-r— EH 1'—EH 1 4.2e 0192a— i