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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENV I RONMENTAL diEALTH 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 in hereby Trade to San Joaquin County for a permit to construct and/or install the York h.rein described Thls application is made in compliance with San Joaquin County Ordinance No 549 and 1862 and the Rules and Regulations of Sen Jcnquin County Public Health services _ t nt) Address C)3 �• lr �� ' J I��_ - (.try 5��4 T t+tai lot S1zeJAcrp++r5c rt^ r If if,, k , er,f4 tu., f I' �;,+ . tOe"� –4 ,� 7 7 Phone+r rte. �cfi5+8 Address r `�1 C �r' %e _ — Owner 9 Name -- � ,ff p STuc ktT (1 i� 7 3 i cgro(Tt L I r]0(A dress _L� (3GX Il'�'f� NI .'RCfc1 tive License No S-aa C f Phone f anlr�Clor1 t�=� et �� T I PE OF WELLIPUMP NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION (1 Out of service Well L-1 PUMP INSTALLATION O SYSTEM REPAIR Cl 3 OTHER Monitoringsµ Z $t. i .- rn21 DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE FOUNDATION AGRICULTURE WELL OTHER WELt PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /r I 1 induotnal 1-] Open Bottom (7 Manteca Dia of Well Excavation �r z Dia of Wall Casing Domestic/Private 0 Gravel Pack L) Tracy Type of C'asinq St�,t�(t/I[ r V Spectlications i 4 I Pilhlrc f 1 Other 1-1 Delta Depth of Grout Seal Type of Grout'e. I I Irrigation Approx Depth I I Eastern Surface Seal Installed by Renarr Work Done U Type of Pump H P State Work Done _ Wall Destruction ❑ Well Diameter sealing Material 6 Depth Depth Filler Material 6 Depth TYPE OF SEPTIC WORK NEW INSTALLATION I I AEPAIRIADDITION 1 I DESTRUCTION I I INo septic system permuted if public sewer is + available within 200 feet 1 I Installation will serve Residence _ Commercial — Other fbimber of living units Number of bedrooms Charoetor of roll to a dopth of 3 foci Woror tablo depth SEPTIC TANK ❑ Type/Mfg Capacity No Compartrnants PKG TREATMENT PLT Cl Method of Disposal -- Distance to nearest Well _ Foundation Properly Line l' LEACHING LINE L1 No S Length of lines _ Total length/size FILTER BED r3 Distance to nearest Well Foundation Property Line \ SEEPAGE PITS 1 1 Depth Size _ Number SUMPS t1 Distance to nearest Well Foundation Property Lino DISPOSAL PONDS ❑ I hereby terrify 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 a signature cenifies the following 1 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 Contractors hiring or sub contracting signature cerliftes the following I certify that in the performance of the work for which this permit is issued I shell employ persona subject to workman s comcenta tion Iowa of California The applicant must callJor allreq red inspections Complete drawing on reverse side Signed X m"' Till Till Lt i,t l , .WC Date 3 — ATN1ENT USE ONLY Application Accepted by Date A(es Pit or Grout Inspection by 'Date �-S loaf Inspection by G dstg Additionol Commanta Applirnnt - ReLurn all copies to San Joaquin County Public llealth Service-3 �`j Environmental Ilealth Perms e')it/ServlceL { 445 N San Joaquin, P 0 Box 2009, 9tkn, rA 45201 FEE AMOUNT DUE AMOUNT REMIT-TED CK RECEIVED By DATE PERMIT NO I MQ �J� //ty� q CASH EH 17:1 inFv i R11 /� 7 ' 6 FH 147e l/ /