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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 D ° PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby milde,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. /� `/n� �'''.�-` Job Address • —0 An 41 C F-� Fes-=_— CnY�.L�-I Lot Sime/Acreage I / J) Owner's Name `�toy /�p Address Sit:-, c^'t e n Phone Contractor ��' '" r`D �C- Addresdde License No3„ ,-, Phon� TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR,$ OTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing i Dominic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications l M Public ❑ Other n Delta Depth of Grout Seal Type of Grout I I Inigation _Approx. Depth �I 1yEastern Surface Seal Installed by .. }— Repair Work Done X Type of Pump H.P. . t State Work Done- o� j�•r/C/ Wall Deswuction O Well Diameter Sealing Material A Depth Depth Tiller Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) �. Installation will sarw: Residents— Commercial_ Other10 / Number of living units:_ Number of bedrooms �• - � �.. Character of soil to•depth of 3 teat: Water,table depth ^• SEPTIC TANK ❑ Type/Mfg .Capacity Nci Companrnents PKG. TREATMENT PLT. ❑ � %. ,Method of Disposal i Distance to nearest; Well Foundation +Property lire ✓ . LEACHING LINE ' ❑ No. 8 Length of lines j+ v Total length/size FILTER BED O Distance to nearest: Wall Foundation Property Line 4s�ig�nature SEEPAGE PITS II Debt` Size NumberSUMPS ! �� LI.Distal"tonearest: 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: itsrules 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 issueemploy any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracticertifies the following:"1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman' tion laws of Cal ' The appli t must as for ell requir inspactionc. Complete drawin0 on raver de. ' /�// n Signed Title: ._.1/!,!p S Date: n^ FOR DEPARTMENT USE ONLY l j� Application Accepted by Date Area, 'Area. Pk or Grout Inspection by Date Final Inspection by R• Dots 4116 Additional Commence: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Servicea 445 N San Joaquin, P 0 Box 2009, Stun, CA 95201 NFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY 0 E PERMIT NO. • fR f 3,24 MEV.Ve 5l 1 T EX t4ie / J