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�I� q SANIN COUNTY PUBLIC HEALTH $ CES „NVIRONMENTAL HEALTH DIVISI 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 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 made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. JJe_5 Job Address �� WQST l.J"larf'i�.r Cl . City -W-y) Lot Size/Acreage J(V] X lzlo/ /O LL/IiverSc.� ci� Plaza- 1�4ve. Ne.CYx`iCk Owner's Name I fCYlmsyl"ItA�S2Tl(I C2S Address • Phone L { �zfTechnology Inc ry01 3 � F�•s�N' D51 rs¢a� 4To4/ C91b)371-`/1Co Contractor f `t! 4 Nc. m�oA- Address 12n x ` Ci 22Z• L License No-T-f` 9}9 CS}Phone TYPE OF WELL/PUMP: NEW WELL Z WELL REPLACEMENT i 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 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS " ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 1n.5 nC11- Dia. of Well Casing I Y111 C.l Domestic/Private A Gravel Pack ❑ Tracy Type of Casing- rnVC Specifications I'I Public I1 Other fT Delta Depth of Grout Seal is Type of Grout •3iu,.�i- I I Irrigation �Approx. Depth I I Eastern Surface Seal Installed by 4 ^n-1"" "1'"'r -- Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Y LA'43 Sealing Material & Depth 2.-•I- - • t . y Y4 1 �x�rOCh c 1 Depfh /C Filler Material & Depth 5rtn(i ii j,"1 y6 - / TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION 1 1 (No septic system permitted it public sewer is available within 200 feet.l Installation will some: Residence_ Commercial _ Other Number of living units: _ Number of bedrooms Character of soil to s depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments v PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size ZZ FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 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 compen tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. t� [1 n Q tK r. -i ST e ✓3D(Url�`i:tDa '1 ' -1 "1 Signed X ` J ht i\u. , �('1wTP.v\ Title: te: 2— T ^FOR DEPARTMENT USE ONLY r Application Accepted by �k• '�� Data _! Area Pit or Grout Inspection by 1 Date �12 C)2— Final Inspection by r` J'�' " — Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services /f �L 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 //i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. INFO I y/�/ C//A.SH . EH 13 34 IREV.I i x 51 (/� "GV�7 r�"�/ ✓ 9�.��J�`i7 EH t43a