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SAN JUIN COUNTY PUBLIC HEALTH S--VICES MV I RONMENTAL HEALTH D I V I S I O.r,,,.,, 445 N SAN JOAQUIN, PHONE (209)468--3420 P 0 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 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 E• YO. c...wti i - it City r r . e'cca. Lot Size/Acreage 0, d r le ,/v o% a /�7 Owner's Name 011e pi m� Address 09� f C,4 95 V c) Phone 2109 5-? SO MUM= 58 i b3`j C7a�)37�f-- Contractor Address License No:- ,�-W_ Phone TYPE OF WELL/PUMP: NEW WELt 'WELL REPLACEMENT CI DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION C3NASYSTEM REPAIR ❑ }-OTHER ❑ Monitoring �ll DISTANCE TO NEAREST: SEPTIC TANK�+'>~SEWER LINES t 6 V DISPOSAL FL/�`�!} P. LINE _1V FOUNDATIONy r AGRICULTURE WELLOA -o1•a4THER WELL t G PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y CI Industrial ❑ Open Bottom Manteca Dia. of Well Excavatey /0, _--- Dia. of Well Casing (�( Domestic/Private Gravel Pack ❑ Tracy Type of Casing_ f" V Specifications f"1 Public 1'1 Other n Delta Depth of Grout Seal Type of Gro I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by 1- �wc 4 ElL Repair Work Done U Type of Pump H.P. State Work Dome_ Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) 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 Pro party Lina LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Pro party Line�-.,. �. kNi r.t E�jTY SEEPAGE PITS 11 Depth Size Number A �_� ;•h�_'!, .� p SUMPS Ll Distance to nearest: Well Foundation Props ; �y1F;\i't HL e, DISPOSAL PONDS Cl 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 fact to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the perfor ante 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 tail alt required i c Complete drawing on reverse side. ��''Soc Signed X Title: _ 'Vf ��-/ CSS J--k1r-e4- Date: ' ! - S_Z- FOR DEPARTMENT USE ONLY �i (� Application Accepted by t Date 2 Area T V Pit or Grout inspection by Date Final Inspection by ` Date3l/Q Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services O Environmental Health Permit/Services 4- 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE INFO AMOUNT ^DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. Il • EN 3-24(REV. EM 14-1eiiKs)