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I� � UBL�I�% �AI;TH i ES SAN WZ'QUIN COUNTY P ENVIRONMENTAL jjEALTH DIV,IISI ,G� PHONE (209)468-3420 445 N SAN �OAQUIN STOCKTON, CA 95201 p 0 BOX 2009 , ,II, ,�' ID �r.Q1/?t&- t i PERM T EXPIRES 1 YEAR FROM DATE u SSU 111 `Priplicate) This (Complete in �I ' the work herein described. for a Permit to construct land install )soars of San made � Sen Joaquin County U tend 1862 and the Rules end Rego Application is herebya deltOtsnce with San Joaquin County Ordinance No. 5 9 application is made 1, Lot Size/Acreage Joaquin Count, Public Health Services. City kath�O California Natural Products �II Phone �-,..•...� .lob Address y � l�} D Address ij � 11 I �11+F7 -��p I L I �I -phone `Q"� pwner's Name ✓ �XoCv v, LiCe.nse Na. �`� well .� t,,pQy�•k Address DES7Fi1JCTlON-❑ Out of Service Wellx -} Contractor �^ WELL REPLACEMENT . OTHER ❑ Monitoring NEW WELL C SYSTEM REPAIR ll +%�! TYPE OF WELLlPUMP: PROP. LINE ! PUMP INSTALLATION ❑ SEWER LINES �- pISPOSAL FLO. PITSlSUMPS r AGRICULTURE WELL r.OT1-IEFI WELL�---- 01S7ANCE TO NEAREST: SEPTIC TANK u FOUNDATION _3Q» PROBLEM CONSTRUCTION SPECIFkCiATtONS Dia. of Well Casing TYPE OF WELL Dia of Weil Excavation ntrr+ creta 4� INTENDED USE ❑ Open Bottom Cl Manteca ;I1I Specifications Cl Industrial ❑ Tracy Type of Casing_- F—' Gravel Pack i II + Type of Grout Domestic/Private }�: Delta Depth of Grout SealIR "` 1-1 Other I'1 Public Depth I Eastern Surface Seul installed by �rp,pprdx. Dep �I Stale Work Done I I lrtigdeion H.P. I � Type of Pump �� Sealing Material 6 Depth Repair Work Bone [� II Well Destruction 0 Weil Diameter �--�- Filler Material 3 Depth Depth stens permitted if public sewer is II availabie within 200 feet.) �- TYPE 4F SEPTIC WORK: NEW INSTALLATION I I REPAiRrADD1T10N l I DESTRUCTtOtd 4 i INo septic sY Commercial _ Other�B ]a 1C] J� PAYMENT Installation will serve: Residence�-. 99; Water fe0v �I Number of bedrooms�.-�- ., 4 Number of living units: No. G Character of soil to a depth of 3 feet: U0 SEPTIC 1 ❑ TypelMfg Meth '�" SEPTIC TANK ' ! OUNTY Property��`1`� PKG. TREATMENT PLT.0 Foundation �� PUBLIC HEALTH SEt�VICES Distance to nearest: Welk �- I� -j I Ian t%yjY ONMENTAL H AL �i vl Tota q C1 No: Line LEACHING LINE �-� Well Foundation I,�_ � Property � FILTER BED ❑ Distance to nearest: I !�. II Number Size�1 i I I Depth Property Line�-�- SEEPAGE PITS Well�_�-- Foundation.moi SUMPS Ll Distance to nearest: ilil j DISPOSAL PONDS ❑ and that the work will be done inlaccordiilce with San,faaquin county ordinances, state las ail not I hereby certify that I have prepared This application 'I"'"- i certify that in the'perfdrmance of the work for which this permit is issued, I nature rules and regulaliona of the Sen Joaquin County tune Home owner or licensed agent's signature certifies the lotto workman's " e work for which this permit is issued, i shali amploY Persons subject to workman's comps n person in such manner as to become subject tohworkman's compensation yaws of Gaiifornia." Contrectot�s Kirin or sub•contracttng signature empldY any>� I certify that in the performance of certifies the following:'� tion laws Of Calif la•" 2 Z applicant st cal for all eq inspections. Complete drawing an reverse side. IF I Date: The app 11111111111111!32! � Title: II SignedI,1! FOR 0 ARTMENT USf ONL1Fi I�I -Date i Area V 3 I Application Accepted by .�I Date Date Fina) lnspecuon by Pit or Grout Inspection by T Additional Comments: unty Pub11clEHeaith Services Applicant - Return alk copies to: gnvironment 1an Joaquin oHealth Permit/Ser�15tkn, GA 95241 ces Cr'- L•�� 445 N San Joaquin, P 0 Boil 200911 K RECEIVED BY PATE PERMtT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH INFO {_}/ Z Z4• L . FN 13,14IREV,t�„S1 P fhi tb2a it