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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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 ^' City Lot Size/Acreage el?f? 1�11rb^e Owner's Name r �L.d G nl - 4L-- ;r� � f'Ftwf oL `fes Phone Dl- Address Contractor Address J L- ,g Aaa r License No.✓S QL Phone ATL TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK ?rDD`_SEWER LINES A r DISPOSAL FLD. PROP. LINE ,r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS T rr ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Welt Casing Domestic/Private 1P(Gravel Pack / C1 Tracy Type of Casing._ ! i I - 7 Specifications FI Public Ci Other �j0 Delta Depth of Grout Seal _ ., � A1� Type of Grout-� E I I IrrigationQ�Approx, De th i I Eastern Surface Seal installed by �Z 3 �A/l IVC r Repair Work Done L3 Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is i available within 2W feet.) Installation wig serve: Residence_ Commercial-__,_ Other t Number of living units: Number of bedrooms P Character of soil to a depth of 3 feet: Water 1a� SEPTIC TANK ❑ Type/Mfg Capacity No. dwyeev PKG. TREATMENT PLT. ❑ Met Itf toistzesal� { Distance to nearest: Well Foundation Property in UU JOAQUIN COU,NJy LEACHING LINE ❑ No. & Length of lines Total len§1f/ M4U f�ERC'f �ERi CFS FILTER BED n Distance to nearest: Well Foundation Property Line N SEEPAGE PITS 11 Depth Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS D W I hereby certify that I have prepared this application and that the work wilt 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 npst call for all required inspections. Complete drawing on r versa side. c — Signed xjeM `A- Title: Date: FQR DEPARTMENT USE ONLY / Application Accepted by Date Area Final Inspection by Date Pit or rout spectio _ Q0,P/MON Additions! Comments: + $��' ` Applicant - Return all copies, to: San Joaquin County Public Healt Services 0Lr/hPi4.A:r1'd Environmental Health Permit/Services j,,, y It, H2_ 0 461t: -`945 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT.DUE AMOUNT REMITTED CK 0 RECEIVED BY DATE PERMIT'NO. IbIFQ CASH + EM I7-2i PIEV.'vn5) EH 11.2E t