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SAN JO✓11PN COATY PUBLIC HEALTH SE :ES hia4IRONMENTAL HEALTH DIVISION* 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 install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. pZaQ �as1" V/G7�7Y /t OUG City 4 Lot Size/Acreage � NQS Job Address /J Owner's Name /Odi OUPV�7epa&/ JPWt/ Address �a� ��sf/�c�or ift2ek4Q4I PhoneC2/� Z33 66/ Contractor&k��SJOc/4��tAddress 1 Q041"- 4t QlefFAM-4f License NoCSF -V9d/YX Phone{✓/ TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT O DESTRUCTION ACtut of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHER O 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 f-T Industrial do Bottom ❑ Manteca Dia. of Well Excavation Die. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications 11 Public I"1 Other fT Delta Depth of Grout Seal Type of Grout I I Inigation _Approx. Depth I I Eastern Surface Seel Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction Well Diameter —See—� Sealing Material a Depth Depth 6y� �RY i9. Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is available within 200 feet.) Installation will some: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of *oil 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-bine: LEACHING LINE ❑ No. 6 Length of lines Total IengtM(.s' a FILTER BED O Distance to nearest: Wall Foundation Prdperty Lfne E!""171 Skill )A (WI, SEEPAGE PITS 11 Depth Size — rNTl��r I H LA SUMPS LI Distance to nearest: Well Foundation ropeny Una DISPOSAL PONDS ❑ 1 hereby cenify that 1 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 certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall employ person*subject to workman's compensa. tion laws of California." The applicant rru tt call for all eq i actions. Complete drawing on reverse side. Sig rue:"/�KH�v �HPii2ns+uaf�t �rytdlDate: .5 /9 9 Z. FOR DEPARTMENT USE ONLY J 7� Application Accepts Date Area Area Pit or Grout Inapaction by Dat Final Inspection by Additional Comments: P Applicant - Return all copies to: San Joaquin County Public ealth Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, 9tkn, CA 95201 Q FEE AMOUNT DUE AMOUNT REMITTED CK I CASH RECEIVED BY DATE PERMIT NO. INFO . EH to SE IREV.rr x a: /t / EH N.a/ F1 0; moi`—' L