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SAN *QUIN COUNTY PUBLIC HEALTHVICES ENVIRONMENTAL HEALTH DIVISI 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOC%TON, CA 95201 Ca, 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 application is sande 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 City 0 ) n Lot Size/Acreage IVT vX )YQ _ ec fy P/az.a- �- Heiorkk Fon k�/l'71 M[n n� .-.]E' r�QAddress &�l✓¢l.�L/` � �� y/�� Phone Owner's Name f ,jl�t5cLCramank,, G3 9'�5LC'/ Contractor G Address NO) 4,04YOJ� 1L-'r Stt «C LicenseNo/��3Y4yZ Phone TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT 7 'DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL-1 PIT$/SU�M�PS CLL 6"a USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS III 6L-&,4 n m�CLL6 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /O,$rn . �r)biq. f Well Casing Ci Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Yy Q.. Specifications I'I Public A Other n Delta Depth of Grout Seal /6 Type of Grout 14A24-C ma I I Irrigation _ Approx. Depth I I Eastern Surface Soul Installed by 1 -t - Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter yr/7• Sealing Material i Depth Alin rv.A-,^.i4e /--za-41 IC arnnn:' TAOr1r+o-i rVDePtn Filler Material L Depth `end IF- 5T.-P4, kJ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i , INo septic system permitted if public er is I available within 200 is Installation will e: Residence_ Commercial_ Other Number of living unit . Number of bedrooms Character of wil to a depth feat: Water table depth SEPTIC TANK ❑ Type/ city No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Foundation Propeny Line LEACHING LINE ❑ No. 8 Length of s Total length/size FILTER BED ❑ Distance earest: Well Foundation Property Line SEEPAGE PITS I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS - ❑ CCr I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, alit 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 workmen'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 must call for all requijAdl Inspections. Complete drawing on reverse side. Signed X K ,'lo rF k1 nrYn LATitle: ,.� e 94 r4C'ifln<'�.'4- Data: I1 , A(J1��1//�JF/.O�fKEPARTMENT USE ONLY Application Accepted by µ!_ "' • "`' '� Date u - Area �� ,1�� q / 1�h,,,, ' I Pit or Grout Inspection by f vJ- V,--1 ode "I Date �qtr-/3 Final Inspection by e ^ I,L(_L.�L'�`_ Date 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, SLkn, CA 95201 �V FEE AMOUNT DUE AMOUNT REMITTED CK a RECEIVED BY DATE AERM17 NO. INFO ^yam^ CASH . EH 11 24[REV rix 51 ^ �— y.,J I `� '�— / •�1` (� G� / /"1 EH 1ope