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arri,i�arl�lr SAlits,,OAQUIN COUNTY PUBLIC FMA Ti 3RVICES ENVIRONMENTAL HEALTH DfVIS,196H 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCgTON . , I A 95201 c- . PERMIT EXPIRE I YEAR FROM DATE SSUEJ '4 (Complete in Triplicate) Application in hereby made.to San Joaquin County far a permit to construct Iandifor install L nst:a lL the-,�syy�°�rf� Attie #ti'd��cri17�ea 1 T}�is applications is made in compllance with San Joaquin County Ordinance No. 549, and 1862 and to HMa aa}d Begulat:}ons.?f San Joaquin County Public Health Services. i Job Address 11273 E. Ada Ave. city Stockton Lot Size/Acreage 6. 3 Services Owner's Name Sierra—Bay Farm Crect"ress P.O. Box 8070 Stockton Phone(209 )531 —3770 Contractor Spectrum Address 2825 E. M rtle St. I. License No. 51 2258 Phone 465-8712 TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT nl. DESTRUCTION ❑ out of Service Weil Ll PUMP INSTALLATION ElSYSTEM REPAIR ❑� OTHER Cg Soinitorl We1J l Bori ng DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Gl Industrial D Open Bonom ❑ Manteca Dia. of Well Excavation Ols, of Well Casing n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 'I Specifications I'I Public n Other ❑ Delta Depth of Grout Seal II Type of Grout \ I I irrigation _Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done U Type of Pump H,P. j State Work Done , Well Destruction ❑ Well Diameter Sealing Material A Depth I� Depth Tiller Material i Depth TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I OESTRUCTI�ON I I iNo septic system permitted if public sewer is available within 200 feet.) t 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 I� LEACHING LINE ❑ No. b Length of lines IToral length/size , FILTER BED ❑ Distance to nearest: Well Foundation Property Line I� SEEPAGE PiTS i I Death Size Number SUMPS Ll Distance to nearest: Well foundation I. Property Line 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 Son Joaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the perforrhance 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 iawed,I shall employ persons subject to workman's compensa- tion laws of California." The applica it mus call for all required ins dons_ Complete drawing on reverse side. Signed Title Date: Y I� FOR D>PARTMENT USE ONLY Q F Application Accepted by !Date r / Area ! Pit or Grout inspection by Date Final inspection by I Additional Comn»nts: Applicant - Return all copies to: San Joaquin CountT Public llealth� Services Environmental Health Permit/Services 443 N San Joaquin, P O Box 2009,.�Stka. CA 93201 2f i FEE AMgUNT Ot1E AMOUNT AEMttTEQ K 11ECI!kl) BY DATE PERMIT�NO. INFO D CASH :� / Q 1/-5?X �N EN t41-20 -`"'FA (II