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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 PERMIT 61RES 1 YEAR FROM DATE ISSUED (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 compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. .. ,2_q06 �/ �� /�F[7E,e l Job Address • • .2 E O ts,�?n�( C,ty AA fM d Lot Size/Acreage Owner's Name 1/k&lY lXagllof"19 re Address .1.2 �P6"4/00lJ c3' Phone -tea�7 .� Contractora&JgAddress4o02_ F-GTiEF , License Na37(o71ets Phpnel2t31-299 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INS7ALLATIONSYSTEM REPAID, I 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 - —❑ Open Bottom - ❑ Manteca Dia. of Well Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications- I'I pecificationsI'I Public (l Other f1 Delta Depth of Grout Seal Type of Grout igation _ Approx. Deyth I I Eastern Surface Seal Installed by .�- Repair Work Done Ll Type of Pump TGAPE/V.6 H.P. 1Jr State Work Done / 2 ,6 /A4A410 Well Destruction ❑ Well Diameter Sealing Material & Depth , Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/AOOITION i I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation writ serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Chersctw of soil to a depth of 3 feel: Water table depth �, SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLL ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE D No. & Length of linea Total length/size FILTER BED ❑ Distance to market; Well Foundation Property 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, 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." Contractors hiring of sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa- tion Iowa of California." The apphcan m-at,cral�l for allrequired inspections. Complete drawing on reverse side. Signed x �GCN X`, j3ft..e Title: �0�� '� Dale: �r�FOR pEPARTMENT USE ONLY Application Accepted by c ih. V l \rg� � Data v ` -,— Area Pit or Grout Impaction by Date Final Inspection by /I[T Date Additional Comments f 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 INFO AMOUNT DUE AMOUNT flEMITTFD CK RECEIVED BY D E PERMIT NO EH 134 IREV.iinm FEE 17IL?EH u.ze I