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G .WV n. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 I 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 I application is made in compliance with San Joaquin County Ordinance Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address Z =96714EIOA CitY -6�1 Lot Size/Acreage i Owner's Name N Llk CD /V Address /� �r`<�� Yom+ 7 _ Phone Contractor Address License No1��Phone ' i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 5 DESTRUCTION i=1 Out of Service Well ❑ PUMP INSTALLATION N( SYSTEM REPAIR C7 OTHER O Monitoring Well ❑ 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 f] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation_ Dia. of Well Casing (momestic/Private CI Gravel Pack ❑ Tracy Type of Casing.- Specifications i'1 Public fa Other I71 Delta Depth of Grout Seal Type of Grout I I Irrigation .-._.Approx. Depth t I Eastern Surface Seal Installed by r Repair Work-Done 0 Type of Pump _ YU6 H.P. 3 A/- State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth n„ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION I I INo septic system permitted if 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 Property Line �( LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED f=1 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS Lf Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lawsr 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 subcontracting 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 m all far all r quired in tions. mplete drawing on�$ . S&A14 Signed X Title: Date: FOR DEPARTMENT USE ONLY `� Application Accepted by Date /� `� L Area Pit or Grout Inspection by Data Final In bys Additional Comments: Applicant - Return all copies to; San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. 1 FO �CASH )Ox . EH 13-24 MEV.I/n W ! ��`- ~�'� ��y 3 EH 14.26 ffVV 7V/� i