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SAN JWUIN COUNTY PUBLIC HEALTH SWCES 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. 54 and 1862 and the Rules and Regulations of San Joaquin county Public Health Services. Job Address n �U�p s `mss-/S C� City J �/ t Lot Size/Acreage /i/�I' / '1 •J/iYFy�l t r— Address•sww 6 s,l Zi yi- //G'?/ .S.-r� �G6 Phone .52/U z 777 3 Z Owner's Name r'r�" L yyJ J��-,Gz-sres�/� Contractor L/V� ,�7 Address �le "3C//��`/`j/�`c— ,�Iicense Nd—'$�7,�7713NPhon,7e 7 37y •3 TYPE OF WELL/PUMP: NE#WELL JJ rar JJ WELL REPLACEMENT rl DESTRUCTION LlOut of Service well LI PUMP INSTALLATION ❑ SYSTEM ppPAIR ❑ OTHER ❑ Monitoring Well ❑ ,n�vm1�-'9�477 wi// 17.55` -lek in DISTANCE TO NEAREST: SEPTIC TANK^a SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION D AGRICULTURE WELL r411 OTHER WELL9�`��-A"'--PITS/SUMPS INTENDED USE MOAT, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z yr L) Industrial ❑ 0 n Bonom [D Manteca Dia, of Well Excavation r Dia. of Well Casing t (1 [-I Domestic/Private ❑ Pack ❑ Tracy Type of Casing_ Specifications I'1 Public rl Other rl Delta Depth of Grout Seal y I? Type of Grout I I Irrigation kfApprox. Depth I I Eastern Surface Seal Installed b, 4,Y/IL- Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number 01 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 ❑ No. & Length of lines Total length/size t1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number I 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 n 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 Ism of California." The applicant must call or all required inspections. Complete drawing on reverse reeverse side. Signed X lTitle: F D(df� EPARTMENT USE ONLY Application Accepted by /)fit/�^"�- Dara Area Pit or Grout Inspection by � Date U Final Inspection by D Additional Commsntc '/la dx is /c`— Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 3501 FEE AMOUNT DUE AMOUNT REMITTED CAS INFO H RECEIVED BY DATE PtWIT NO. EHtMx(REV,irx5, �9 g9, qog A 3-9-9 3 3 o EH lx.m