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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, STOC%TON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) � �S i -Z-C'l S-Hr6rt/✓✓a 4 Application in hereby made to ban Joaquin County for a permit to construct nndlor Install t�e U;herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549549 a�and the Rules and Regulations of Sm Joaquin County Public He i,h Services. 1 '�• I u D �— �� x •— a_I .V q C,Iy Lot Size/Acreage 'J I Job Address t—Pt--- � Phone 3 35 Dwrr'a Name • Address - ro Contractor L Address License No. a (o Phone I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION U Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ _ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE j+ FOUNDATION AGRICULTURE WELL OTHER WELL ! PITSISUMPS—_ l� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ Open Bottom ❑ Manteca Dfa. of Well Excavation Dia. of Well Casing I Domestic/Private ❑ Gravel Pack El Tracy Type of Casing_ Specifications I /I PuWic it Other^•�� f'1 Ostia Depth of,Grout Seal yDe of Grout inlnivanon /// Approx..0ee`t'hI.,�I I Eastern S�urrf�ace Seal Installed by /Repair Work Done U ,Type.of Pump r.)�C.O— —H'P" I-EJ I State Work Done Sealing-Hatefial i Depth Well Destruction O Well Oismatef .—/-a-- Depth �a-1f� / filler Material &'Depth TYPE OF SEPTIC WORN:/•NEWINST�ALLATION'IJ,REPAIR/ADDITION I-1 DESTRUCTION I I IN septic system permitted if public sewer is available within 200 faet.l installation will serve: Residence_ Commercial— Other Number of living units: _ Number of bedrooms Character of wil to a depth of 3 feet: j WSIft g'y'A - SEPTIC TANK ❑ Type/Mfg Capacity I No PKG. TREATMENT PLL ❑ ✓' - I e M � q �ls�ppls4a��S Distance to nearest: Well Foundation Property 111}5_,.L i ,A/3}tIN (;41�NTt LEACHING UNE U No. & Length of lines T.oi 1 Isn9th�'3 q,ouF�SER ELLS FILTER BED ❑ Distance to nearesC Wall Foundation LrN , yVIt;9NTAL NEALSN t SEEPAGE PITS 11 Depth Siva Number _SUMPS CI Distance to nearest: Well Foundation _ Property Line ,. _ _ - DISPOSAL PONDS ❑ ' I hereby trinity that I have prepared this app!icationand that the work will be done in accordance with San Joaquin county ordinances, state laws, antl rules antl regulations of the San Joaquin County ._ _ '—" Home owner or licensed agent a signature certifies the following: "1 certify That in the perlormenca of the work-for this permit is issued, I shell not employ any pare n1n such manner as to become subject to workman's compensation lawn of California." Contractor's hiring or rim, signatu certifies tM awing: "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 1 Ca ala." The appl- t st call for all regio ad inspect os. Complete drawing on revere ids. ` Signed Title: Date: FOR DEPARTMEN USE ONLY /fes' 7 _ Application Accepted by 'Date / /i Area Pit or Grout Inspection by Date Final Inspection by Date I Additional Comments: I r Applicant - Return all copies to: San Joaquin County Public H/Servicervlces; Environmental Jo Health permit/Services 445 N San Joaquin, P O Sox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 9y DATE PEAMIT'NO, INFO /^ L'/` �^(�F/J . ER I11R IRfV.r,n a� PR; Vim/ ADO / � / � y / old fR w]e I