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SAN 'QUIN COUNTY PUBLIC HEALTH VICES --r24V I RONMENTAL HEALTH D I V I S I ob- 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or instahan � sc bed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 an t jjj�� R ''"'��t ons of San Joaquin County Public Health Services. Job Address / �• �� City Lot Size/Acreage L 'I J• r/ � •7_ Owner's Name `�f(bur ' V 11 t S Address : '2-Ind "hC�uS��GI �r t Ve- Phone Contractor Address 1526 /05eml� Vl2Cense No. 47 7 qolg Phon TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION'X SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well �Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPQSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C l Domestic/Private ❑ Gravel Pack O Tracy Type of Casing__ Specifications I'I Public L1 Other C-I Delta Depth of Grout Seal Type of Grout (\ I I Irrigation __ Approx. h I I Eastern, .�S.urface Seal Installed by Repair Work Done LJ Type of Pump hz H.P. 1i�r?l1LIG 64- State Work Done / m Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth �\ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) _ Installation will serve: Residence _ Commercial_ Other PAYMENT ��p t`r Number of living units: Number of bedrooms PA T qtr`E T Character of soil to a depth of 3 feet: �f6A'1311 'iy ff P axRta�a;Irl 'r� �vu/ PKG. SE'klC PLT. p Type/Mfg Capacity Utho. ot'DT- Z Distance to nearest: Well Foundation C:OUN Y PUBLIC; 1-'F_ ...: _:�41 , a LEACHING LINE L1 No. b Length of lines Total) hi K%��tlt(�1 AL h`r"I rl ui7T��cT�— FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS L-1 Distance to nearest: Well Foungation Property Line DISPOSAL PONDS ❑ r I hereby certify that I have prepared this application and that the work will be done in accordance with �an 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 certifies 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 C nia." The applic t st c r required inspe.cti s. Complete drawing on reverse side. lis Eh�l. - v Signed Title: Date: OR WARTM USE ONLY / Application Accepted by Date Area �L Pit or Grout Inspection by Date Final Inspection by 1Ia � Additional Comments: ,Applicant - Return all copies to: San 38aquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEEk7UNT DUE AMOUNT REMITTED RECEIVE BY DATE PERMIT'NO. INF�OJ( / f CASH ' . EH 13-24(REV.1/"5) '� I— � V/ �J% �/ —c,2 EH 14,MtG