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SAN J 'IUIN COUNTY PUBLIC HEALTH S +`VICES `CNV I RONMENTAL HEALTH D I V I S I O,ro� 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 0iT , S,��'��v, , ' .•s it,� PERMIT EXPIRES 1 YEAR FROM DATE ISSUID (Complete in Triplicate) t�:V�. ., �;�.r' ^�-L_:! 4 'y Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein descri`lietiC application is made in coaplience with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address I YlI, 'Jc--, to C>v�TEQ— S�% City 5-WC*_1it'� Lot Size/Acreage -Z Owner's Name C•KCE2%'Zc •JS°' VZt-22 :.V5 CC Address R a Phon� Sipa iZ-�'�ncr.i Cq 4.5�5�—�`gC� Contractor KVILRA�- Wress t10c1 L kyj V i J% LA^ , C0MC60 License No.C5-l-'��ZtAOPhon i0 aS- 6t TYPE OF WELL/PUMP: NEW WELL-_ WELL REPLACEMENT Cl DESTRUCTION a Out of Service well O PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK '> IQC rT. SEWER LINES 7 iC f'{ DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Industrial O Open Bottom O Manteca Dia. of Well Excavation c Dia. of Well Casing I' Cl Domestic/Private O Gravel Pack ❑ Tracy Type of Casing 15C" `FL 14 C. Specifications 0 -40 r-f-A K I'I Public ,Other _5z � Depth of Grout Seal 2-0 rFP_T Type of Grout NP trr CeMF- 't W� I I Irrigation _Approx. Depth XEastern Surface Seal Installed by'Q;--P.-tz 5 UiL,?-)-M Ts Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Dista o nearest: Well Foundation Property Line LEACHING LINE O No. b Length of lines Total length/size FILTER BED O Distance to Weare Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Foundation Property Line DISPOSAL PONDS O 1 hereby certify 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'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 ust call for all required inspections. Complete drawing on reverse side. Signed X �^�` f�_ Title: �^1✓a[ o�.��s-�' Date: a� FOR DEPARTMENT USE ONLY Application Accepted by Date ( �' Area Pit or Grout Inspection by 1 Dat/e, A Final Inspection by Data t✓ Additional Comments: t Es k- VVI CoS+ (It, � i-S MILS*(W1 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. INFO CA S�Hf tl�trel y�y � . EN 13-24(REV.r/A31 1.3Qv2. ■ "�1' i 041-12 q2- EH 1♦-2e