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SAN JOAQUIN+COUNTY PUBLIC HEALTH SERVICES i ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 f I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquln County ror a permit to construct u dl,, S,,tal-1 the ,ork herein described. This application is made in cospllance vith San Joaquin County Ordinance No. 5119 and 1862 and the Rules and Regulations of San Joa4uin County Public Health Services. Job Address S a- x/ 1��9D C C' SS rti+i// / City �/x-L Lot Size/Acreage 't0 � Owner's NameE / u4e /AvA Address D J 3•SL3 Phone !..]! I I � Con if ac for ea, I% �j F(a� Address �A azsyw z.2Oy License No37738s Ph,na334-VA`r TYPE OF WELL/PUMA. NEW WEL WELL REPLACEMENT 17 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION, SYSTEM REPAIR ❑ OTHER ❑ Monitoring well LJ t DISTANCE TO NEAREST: SEPTIC TANK SS SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ I, INTENDED USE TYPE OF WELL'S PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial 71 Oven Bottom_ ❑ Manteca Dia. of Well Excavation_[_�__ _^ Dia. of Well Casing Domestic/Privale iZGravel Pack ❑ Tracy Type of Casing_. 11i Specifications `-tog VI Public ❑ OtryaYLa fl site Depth of Grow Seal L9 t"0 Type of Grout c'c A%4A.I I Irrigation ` &T App/roa. Depth Eastern Surface Seal Installed by C e,4'la�•AaTiA. 'Repair Work Done ❑ Type o�PumD Syd H.P. ! State Work Done Welt Destruction ❑ Well Diameter Sealing Material a Depth Depth Filler Material Z Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is -��r available within 200 feet.) Installation will serve: `Residence_ Commercial_ Other umtisTbf Irving -ifs � Number of baCrooms�-'-- - haracter Cof sod to a depth of 3 first: Water table depth SEPTIC TANK ❑ Typa/Mfg'r'1' r • - Capacity No. Compartments PKG. TREATMENT PLT. L) ( ` l _• Method of Disposal ~ Distance to nearest: Well Foundation_ Property Line LEACHING LINE ❑ No. R Length of Tinea 1�____._ Total len�thlaize FILTER-DEO/ CI Distance to ""best: Well Foundation Property Line SEEPAGE PITS It Depth Sin. SUMPS - Lt Oistance to nearest: WNI '- —�'Founciaiion. r Pro party Lina D)SPOSAL PONDS ❑ I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, end rules and regulations of the Ssn'J"quin County `` I ,_,l 1 Rome owner or licensed agent's slgnaturo certifies the lolowing_Jf cartify that In:lhe peOn mance-of the work for which This permit is issued, I shall nor employ any person in such manner asrto 4ecbme,sublact-loviorkman's compensa�lo-n W"f Celifomb ia." Contractor's hiring or sub signature certifies the following: "I certify that inihe performance of the work-for-which thisrNnilit is,issued,1'ihell employ persons subject to workman's compensa tion laws of iCalifornia.- The applicant mus all f i; i'q`k & i'nspectiona". Compiler-e1t:e"tl.r�ewi�tg-on reverse side. Signed / ,Title ASM•— Data: FOR DEPARTMENT USE ONLY 7 IrAADplitation Accepted by- ' Date "'Ir - / �z- Area � ,y / Pit or Grout Impaction by ate G_3_ 12-Final Inspection by Dote 9 `�Z dditional Comonkents: 1 -Applicant.-. Return all copiee•to: San Joaquin County Public Health vices Environmental Health Permit/Services A' t- 495 N San Joaquin, P 0 Box 2009, Stkn, CA 95207. INF AMOUNT DUE AMOUNT REMITTED ST'TTE.D CASR RECEIVED BY // DATE PERMIT'NO. .,,�.ER IaEV:rr sal �� a ENEW14� t