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SAN JUIN COUNTY PUBLIC HEALTH SVICES 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 application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public HealtGh Services. I Job Address`D�tn0��sw7 a) '� I,Z e1�1' �, City �ryz/ Lot S i ze/Acreage Owner's Name 64hVd'`t'r �WR� Address ay�'� ✓l1J�tr^fin^ A14G', fi'� Y�� Phone �L' 2 7232 Contractor ✓✓�1��! Address pC/} 334 ' %z!C 1�j5A ��'¢ License No.1/�S� S4'!�;�Phone C7 y �7 TYPE OF WELL/PUMP: NEW WELL X Mk!1 WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION rAk SYSTEM REPAIR C OTHER C Monitoring Well ❑ w"/ S/t r DISTANCE 70 NEAREST: SEPTIC TANK � SEWER LINES (✓ DISPOSAL FLD.�`T PROP. LINE FOUNDATION '^ /� r AGRICULTURE WELLf ""r OTHER WELL 6a �D """PITS/SUMPS _ INTENDED USEA10' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2 rr ❑ Industrial ❑ 0 n Bpnom C Manteca Dia. of Well Excavation _' � Dia. of Well Casing 7.1 Domestic/Private XG, aeI Pack C Tracy Type of Casing .SQA- Specifications ' CLO S� 1"I Public (-.I Other i::Other Delta Depth of Grout Seal 171 gt," Type of Grout Aa �_2__ I I Irrigation Approx. Depth 1 I Eastern Surface Soul Installed by wr/�G✓ //-SRc,� S��/r��/ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material It Depth Q TYPE OF SEPTIC WORK: NEW INSTALLATION ! i REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted it public sewer is available within 200 leet.l Installation will serve: Residence_ Commer5al_ 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 0 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby cenify 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 workmen's compensation laws of California." Contractor's hiring or sub-contracting signature candies 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 California." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X Title: •f'`'^'cr ��yc/.Sr Date: FOR DEPARTMENT USE ONLY Application Accepted by p Date 1Q�6 �6 AreaC Pit or Grout Inspection by Date 7 Final Inspection by 4-Date Additional Comments: IN67T Applicant - Return all copies to: S�2 Joaquin County Public Health Services 107 Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 U(U INFOCK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. 350/ . EH U-2,IREV.i,hpt �'f'33�� EM t�.m