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--� .. r _ t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 M PERMIT EXPIRES 1 YEAR FROM DATE ISSUID (Complete in Triplicate) Application in hereby made to San:Joaquin County for a permit to construct and/or install t work application is made in compliance!-with San Joaquin County Ordinance No. 549 and 1862 and theeRule'saaadreRegulationsdof Sans ( Joaquin County fPublic 7Health Services. Job Address n ;�+s f t" rr r City � Lot Size crew e Owner's Name h I-O 14- I AJ Address Phoneb� �� II ' Contractor NIr S Sir T.'C � � o. Address 490 67 � ��"S r License No, Phonp/ C TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L❑ DESTRUCTION C Out of Service Hell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER p Mon mooring Well C7 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 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Weli Excavation ' to Domestic/Private ❑ Gravel Pack 1; ❑ Trac Dia. of alioWelCasing Il Public y Type of Casing_ I Specifications fa Other I1 Delta Depth of Grout Seal I 1 Irrigation A Type of Grout —. pprox, Depth I I Eastern Surface Seal Installed-by Repair Work Done L7 Type of Pump H.P. State Work Done Well Destruction D., Well Diameter, - - Sealing f4iterial 4 Depth `Depth j Filler`Material ti Depth V . TYPE OF SEPTIC IIVORK:t NE1NrINSTALLATION 1 I PAIR/ ITIO .1 DESTRUCTION i-1 INo septic system permitted it public sewer is Installation w71 serve; Rt3sidence^ Commercial Other ` ;� available within 200 feet.) r Number o1 living unite: �Number of bedrooms Character of soil to a depth of 3 feet: �` "` .. SEPTIC TANK Water fable depth ❑ Type/Mfg + r -'ice � f Capacity_ PKG. TREATMENT PLT. ❑ fell Na. Compartments ///^^^ Method of Disposal {� Distance to niaest V foundation I . r. _r Property Line LEACHING LINE L��, 8 Lerigthiof:lines Total length/size FILTER BED ❑ Distance tp neareki: Well._ SO -�-Foundation- - -�_pr'operty Line's-- SEEPAGE PITS Depth Size Number SUMPS 0 Distance to nearest: Well- /,70r Foundition; to DISPOSAL PONDS ❑ Property Laine S I hereby certify that I have prepared this application and that the work wiff 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 shalt 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for I required inspe tions. Complete drawing on reverse side. Signed � Title: o Data: FOR DEPARTMENT USE ONLY Application Accepted by or Date Area it or Grout inspection by �7 �+f -,c 2 Final Inspection by Dat��T�,� j Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental HealthPermit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE IN AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED 9Y DATE PERMIT'NO. + EH 144 iREV.tinsr �t C EH 14411