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Hifi'L 1\..l 1l.1 uil .b SAN J"QUIN COUNTY PUBLIC HEALTH MVICES VIROM&E.NTAL HEALTH DIVISIMW 00 PYY 445 N SAN JOAQUIN, PHONE (209)468-3420 ' P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDel � d/S00 // (Complete in Triplicate) Appllcatibn is hereby mede.tc an Joaquin County for a permit to construct and/or install the work herein described. This application to made in compl nnce with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. / p Job Address geltx SuHar-CoT_�arz Cal't0Cnt-c1 DI ia"t City=r-IL(/ Lot Size/Acreage //00 rbc rPs Owner's Name {IX su oy�o'��°oYa�ibr� Address r'Q �Ox K�� Trctc� �/f 9537 Phone,a0Q�g3� c� ys74�a C 6 7 Contractor West fladlqk D1111in CoY Address 30.23 F-49ger4st-0Re-c 0 (61410yAI icense No.55�g7Q Phone % 63S -7):7� TYPE OF WELL/PUMP: NEW WELL ■ WELL REPLACEMENT C1 DESTRUCTION ❑ Out of Service Well (1 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ (#4onitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES Over SO Fent DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 7 D" C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /O inches Dia. of Well Casing C l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingPVG scWole 40 Specifications 0.0/011 sfo�s 11 Public 1-1 Other F1 Delta Depth of Grout Seal 611-Feet or I'rss Type of Grout I I Irrigation 410 (^f Approx. Depth 1 I Eastern Surface Seal Installed by west' HdLA14-f An jjr�q (or�0�'Ca.rtre�e� Repair Work Done L7 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth be•rfronr fe gel/eta •t ag feet or fess � Depth Filler Material i Depth Silica S4-to( f�Pr flack'IE '�0 {rel -r less TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is C 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 PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation_ Property Line LEACHING LINE Cl No. b Length of lines Total length/size _. FILTER BED 0 Distance to nearest: Well Foundation Property Line J• 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." 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, 1 shall employ persons subject to workman's compensa • tion laws of California." The applicant must call for all required inspections. Complete drawing on reverse side. q Signed Title: 6pd c,!i�ry1 ro Coll?, Date: FO=MENT USE ONLY Application Accepted by (1Date �^ Area Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: IJ 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 INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT NO. • EH 13 24(REV.rix51 C EH 14.24 i oe �-