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y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 5 n� -)os-37 )os-37 P O BOX 2009, STOCKTON, CA 95201 � K ' PERMIT EXPIRES 1 YEAR FROM DATE ISSUED c, wx p QPaV (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 coatpliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address iJ ��7 E-t/411P0 ,6 City K t Lot Size/Acreage Owner's Nam aZ4494 iK eifir, Address G r/t'f Phone Contractor k04LC Address 'Q License NO3 2 6 Phone -"?g TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR W 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 Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications I'1 Public ❑ Other ❑ Delta Depth of Grout Seal - Type of Grout ` lyrisgation —Approx. De th I Esstern Surface Seal Installed by 99 2 Repair Work Done kF Type of Pump ✓7 I � H.P. 4 State Work Done Well Destruction ❑ Well Diameter Bealing Material i Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) (� Installation will terve: Residence_ Commercial_ Other •.Y�� Number of living units: _ Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size r FILTER BED ❑ Distance to nearest: Well Foundation Properly 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, an rules and regulations of the Sen 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 no 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 followin unify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensat tion laws of C rnia." The applic must c or all required i pections. Complete drawing on rev/fir idide. Signed C Title: Tp Date: t /� M n�T� _�FOR DEPARTMENT USE ONLY Application Accepted by (dC.L�M N„&f A 1) Date � °Z � as Pit or Grout Inspection by Date Final Inspection by-r Date / 1 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services n 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. (J(/ NFO . 11 taN IREV.rrx51 , L'+.Jr/ I � ,93 93� 620 EH;34 24