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SAN JOAQ TL�„IN COUNTY PUBLIC HEALTH SERVICES ;j20 t:3 S7.713 EN RONMENTAL HEALTH DIVISION ,5a;l �Wt� 445 N �Q JOAQUIN, PHONE (209)468-�0 �S 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 rPuublljic Health Servi�Jces./� �/� lob Address (P� 15 r ACI�C/ /'�VZ r City SYLPC�*�I Lot Size/Acreage ` )wner's Name ChtVrm Address PD Bolt!SaD-V S-an klncai, 95'513 phone gTZ 1DM ontractor 1 SII/11 Address PO AW ZZ3V License No. (0_?ZJo0Q Phone 957- 9SS$ -YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ SDt( OTHER�, . Monitoring Well ❑ )ISTANCE TO NEARES • SEPTIC TANK SEWER LINES v� DISPOSAL FLD. PROP. LINE OUNDATION AGRICULTURE WkLLLl7"T7"'OTHER WELL7� PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIOP.§ I Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing .l Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ XJA— Specifications '1 Public Cl Other n Delta Depth of Grout Seal N./-- Type of Grout `7T L�;,wAr I Irrigation _Approx. Depth I I Eastern Surface Saul Installed by epair Work Done U Type of Pump H.P. State Work Done _ Jell Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth YPE OF SEPTIC WORK: NEW INSTALLATION I 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 soil to a depth of 3 feet: Water table depth EPTIC TANK ❑ 'Type/Mfg Capacity No. Compartments KG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line :ACHING LINE Cl No. & Length of lines Total length/size LTER BED 0 Distance to nearest: Well Foundation Property Line EEPAGE PITS 11 Depth Size Number JMPS LI Distance to nearest: Well Foundation Property Line ISPOSAL PONDS ❑ iereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and les and regulations of the San Joaquin County 3me 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 nploy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature rtifies 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- In laws of California." toapplicant all for all required insPections. Complete drawing on rev se side. gned Title: Date: rfik FO DEPARTMENT USE ONLY )plication Accepted by r�" s� Date 9,2271S Area ��♦� or Grout Inspection oy Date Final Inspection by Date Iditional Comments: 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 CASH RECEIVED BY DATE PERMIT-No. (REV.,,hsi _� ou5tio j AW,,p