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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIV ' 445 N SAN JOAQUIN, PHONE (209 468-34 # ANI P O BOX 2009 , STOCKTON, CA 95201 ^^�./ PERMIT RES I YEAR ROM__D E ISSUED Jd� (Complete in Triplica ) # 01V Application is hereby made to San Joaquin County for a permit: to construct an o application is made in compliance vitt, San Joaquin County Ordinance No 549 a 1862 and the Rules amd RegulatIVId Sar Joaquin County Public Heal "Ueft 17 Job Address Caltrans/ 0 " " Street city Stockton Lot Size/Acreage UTAOwner a Nppme Caltrans ss 6 E. Charter Wa Stockt n Phone - Ma1i ornia Department of nspo ation) W. Sacramento 1 Westex Coneratior .5.ddressP-b. Bo 16b9, CA 95691 L,cense too G--57 552 Z9BPhane) 173-1118 t TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT [1 DESTRUCTION Lq out of service well ❑ PUMP INSTALLATION w SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well )a 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 0 Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia of Well Casing ' n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications l 1 Public (I Other n Delta Depth of Grout Seal Type of Grout I I Irngauon —Approx Depth t l Eastern Surface Saul lnsujiad by ' Repair Work Done U Type of Pump H P State Work Done — Well Destruction © Well Diameter Sealing Material L Depth Depth Filler Material 6 Depth ' TYPE OF SEPTIC WORK NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIONI f system permitted d public serer is PAY --thin 200 feet I Installation will serve Residence _ Commercial — OtherRECEIVED k Number of living units Number of bedrooms ��Y 2 3 ` ZZ Character of soil to a depth of 3 foot 'Mr table depth SEPTIC TANK ❑ Type/Mfg Capacity r &H09PIN rtrnants PKG TREATMENT PLT ❑ PH ALT, ��on'e ' Voosal Distance to nearest Weil Foundati MGNMEN�r'YrA�l Lt LEACHING LINE 0 No 8 Length of Imes Total length/size FILTER BED O Distance to nearest Well Founaation Property Line SEEPAGE PITS 11 Depth Stre Number SUMPS LI Distance to nearest Well Foundation _ Prooerm Line DISPOSAL PONDS ❑ 1 hereoy certify that I have prepared this application and that the work will be done to accordance wrthSan Joaquin county ordinances state Laws, and rules and regulations of the San Joaquin County Home owner or licensed agent's signature oamfies the following I certify that in the periarmance of the work for which this permit is issued 1 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 certrftea the following I certify that to the peRormance of the work for which this permit is issued t shall employ persona subject to workman a compansa tion laws of California " The applicant mt,s1�ail/or all rolqurr�twns Complete drawing on reverse side � f Signed X` An�-� Title Sr J0 1K � e OR DEPARTMENT USE ONLY Application Accepted by Date . Area _ Pit or Gratis Inspection by �t ,nal Inspection by Date Addmmnal Comments Applicant - Return all copies to San Joaquin County lie Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 CK 9 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9Y DATE PERMIT NO 11Page � S EK 17 24 InEv „R Sr /�t'S ZoZ l+ f fN 14 a0 (�/