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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 'JPSAyXJ PERMIT EXPIRES X YEAR FROM DATE ISSU (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install thelYAP. 2e4119aribed. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. oo TH r�" 111 Go E1VlRONME Job Address p �J C!it�y QCA ® �C[� ; Owner's Name SO r Addressp. T y r R 6 6qg,-A, + �gtwo► Cg I G) - Contractor LM�s=� NV iAA_,1&e Address License fVo.�. q Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 1-7 DESTRUCTION Cl Out of Service Weil ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring well 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 i�� 1-,iJVfe_ 3 -SJQt it,►G Dia. of Well Casing ►+� 1�Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excav�a'ti�o�n� _r_.�_... 9 N Domestic/Private KGravel Pack 0 Tracy Type of Casing_Lv_-c.,' "'_� Specifications I'l Public f-1 Other f F1 Delta Depth of Grout Seal " + Type of Graut ►i I i Irrigation _J4W Approfr. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Bone _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is ^� available within 200 feet.1 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: Welt Foundation Property Line bA LEACHING LINE ❑ No. & Length of lines Total length/size I FILTER BED 0 Distance to nearest: Well Foundation Property Line iel mi? I SEEPAGE PITS 11 Depth Size Number AN f 92 kirlLt SUMPS E I Distance to nearest: Well Foundation Property Line' EN ,4� NTy DISPOSAL PONDS 13 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances �Md rules and regulations of the San Joaquin County 1 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the pertormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X_ Title: Date: - _ Date: F0111 n PARTIMENT USE ONLY y Application Accepted by Data 2,- ay-C� Arse y Pit roti napection 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 F CIC RECEIVED BY DATE PERMIT'N0, EE AMOUNT REMITTED AMOUNT DUE INFO CASH CH i "' 1 REV.t n Si ,�q. Q� Z ,.,C !,�}y_F �I-1 �[y► EH 14.26