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SAN *QUIN COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL 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. / Job Addressro�� / �s�j a/ '�' `c L/�C ,97/x`• City 3' c/4Lot S Size/Acreage (�7 Gvt--C LG"Qu'6,f1!/1'1 Address o�UDIJ �r'L%I✓�a�r Yf %Ll, Si l- yl0 Phone 1/J 2 72�JZ Owner's Name � /_/tom mow.trn�C19 1Y �5 I- � Contractor /NfL.�k<"r�/ ✓✓�/��/ Address 10re33L /C L1SA 1//'� License Na4:S7 5-8/i-3/`Phone 07 y �� TYPE OF WELL/PUMP: NEW WELL JQ MIL'I WELL REPLACEMENT M DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 0 OTHER ❑ Monitoring Well ❑ aK DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._' �Pp OP. LINE FOUNDATION /G r AGRICULTURE WELL1 'ter OTHER WELL�G'G PITS/SUMPS _ INTENDED USEA10' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO_ f�S u ❑ Industrial ❑ OoSelnn Bpttom ❑ Manteca Dia. of Well Excavation �" Dia. of Well Casing 2 Ll Domestic/Private x4g,Pack ❑ Tracy Type of Casing <A yC /�i1L- Specifications Q SC 1'I Public f I/OOther fl Delta Depth of Grout Seal Type of Grout �+rf I I Irrigation bi Approx. Depth I I Eastern Surface Seal Installed by.411�W //-Sec% Seo/Yy Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of wit 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 C1 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 ❑ 1 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, 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 Title: `Sdn ru✓ �itG.Gca,/sr Date: z Z f i F R D PARTMENT USE ONLY O Application Accepted by a'-1"�1__" - Date Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: YIoT— Applicant - Return all copies to: dU Joaquis County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 Z AMOUNT REMITTED CKRECEIVED BY DATE PERMIT NO. x3501 CASH EH;32x1AEV.r/x5) ( ?r7 �! ` 33/� EH 14]e