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SAN .. .aQUIN COUNTY PUBLIC HEALTH ..VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1s hereby made,to Son Joaquin County for a permit to construct and/or install the work herein described. This application is rode in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ,•,(�.� /� (ge 1j , rA6L--ToA CityLAJO Lot Size/Acreage Job Address `�"�" 7 _ Owner's Name-VC-9—Ani-VC-9—Ani ��f]MES Address �"."' q.5_23(6/ q.� fp Phone �Sb .IC FCG_A Ttyt�,[ Contractor Address License NO.5 L_r� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION P-/ SYSTEM REPAIR G OTHER G 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 Dia. of Well Casing V" ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications— P6omeI'] stic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Type of Grout V 1'I Public 1-1 Other it Delta Depth of Grout Seal I I Irrigation _Approx. Depth II�IIE�Eastern Surface Sealnlnstalleci by Repair Work Done LJ Type of Pump �1L.O- H.P. 'Sf�y State Work Done G Sealing Material A Depth Well Destruction ❑ Well Diameter ti Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo seplic system permitted if public sewer is 1 available within 200 feet.) Installation will serve: Residence — Commercial_ Other 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 f� PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line \ SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 csitiNs 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 compensa- tion laws of California." The applicant1t)Call forallrequiredDate: rol Tinspectio . Complete drawing on r arse aide. /7 I ^� Signed Y L�+f�^" "�� Title: O - R EPARTM ENT USE ONLY Cy Ali Application Accepted by Q `+ Date L - ` Area -&2- ... Date Pit or Grout Impaction by Date Final Inspection by Additional Comments: .a. Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE CK RECEIVED 8V DATE PERMIT NO. INFO AMOUNT DUE AMOUNT REMITTED CASH SRa9�-3 `1 3