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� •� 4npT IC.�m_01. SAN AQUIN COUNTY PUBLIC HEALTH o RVICES ENVIRONMENTAL; HEALTH DIVISION 445 N SAN JOAQUIN.; PHONE''(209)468-3420 P. 0 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 t application is made in compliance with San Joaquin Coun y Or Want No. 549 and.1862 and the Rules and Regulations of San Joaquin County Public Health Services. M`P 6[�� i Job Address ` City ':LO'D( Lot Size/Acreage � .�•� i Owner's Name DY Address 7-4 i l 5 Phone i M-mril �TZW,5 '7T'OTS , 151 Contractor Address ALO Beg 117-1 + ?rAeK5A1.1 G,Pt License No.S�s�SZ Phone I 'TYPE OF WELLfPUMP: NEW WELL ❑ - WELL REPLACEMENT M . DESTRUCTION ❑ Out of Service Ke11 ❑ 11 "I aitoring Kell PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ Soil $o r,n9 OTHER Mon ❑ `3 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 ExcavationDia: of Well Casing- 17.1 Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_.il-OWE Specifications i i'1 PublicOther I-1 Delta Depth of,Grout Seal. c,� Type of Grout ,±, r I i Irrigation I �Approx. Depth I I Eastern Surface Seal Installed by I' Repair Work Done 0 !i p Type of Pump H.F. '.. Stats Wgrk Done Ii Well Destruction ❑ Well Diameter Sealing Material & Depth (�W�Qr4f1 35 Soto B�Ctih b� r, :. J '.i Depth Filler Material 4 Depth E9 j TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/A00ITION l I . DESTRUCTION I i INo septic system permitted if public sewer is available within 200 f t.I Installation will serve: Residence Commercial Other I Number of living units:.' Number of bedrooms _`'�'+ 'I 4 lj Character of soil to a depth of 3 feet: fePle' tf� SEPTIC TANK ❑ Type/Mfg Capacity [tltpE�Crtinents.. PKG. TREATMENT PLT. ❑ b Set}` �o D�n�asm •. I Distance to nearest: Well Foundation Pr LEACHING LINE ❑ No. & Length of lines 7atall size I! FILTER BED ❑ ,Distance to nearest: Well Foundation Property Line E SEEPAGE PITS I 1 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ �1 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 C rules and regulations of the San Joaquin County r 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 workmen's compensation laws of California." Contractor's hiring or subcontracting signature I certifies the following: "I certify that in the performance of the work for which this permit jar issued, I shad employ person subject to workman's compensa- tion laws of California." i The applicant must call for all required inspections. Complete drawing on reverse side. rr Signed X F47& Title. fL� Geotf�IST �Z I ? O- _. Date: FOR DEPARTf14ENT USE ONLY I Application Accepted by F DaArea te i� Pit or Grout Inspection by e Final Inspection by" � Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services a��jC7 i; 445 N San Joaquin, P O H.ox 2009, Stkn, CA 95241 _ INFO FEE AMOUNT OUE AMOUNT REMITTED CASH CX t RECEIVED 8Y DATE PERMIT'NO. JI n6 •:Ell 13-24 IREV.r i M s) f