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SAN { 1QUIN COUNTY PUBLIC HEALTH :VICES %-12iVIRONMENTAL HEALTH DIVISI 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT SPIRES I 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 Address 7303 "c/1-1-1c 1411EMUe City f7V4:X770V Lot Size/Acreage 49 AI S acT,iv 7-.,KA?rye Ei¢a ,eFA16!11d4r"11Vd6- . ,Z,rci ST,ywwEc c— � 'r/eo�co vco.PD, CA Owner's Name UA/oC-4-L �yRPo,t�AT/oN Address �� S S'!�� .V C4 9�hane.Seo 17,7-,2 3 Contractor PG�rP✓/�N _ �41Mr Address�a �/f L/NDfJV G9 IS.l36License No.GS -3779 Phone�fP17-3s TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ?'1 DESTRUCTION F= of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C- Monitoring Well ❑ 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 Cl Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing fA Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications Il Public [,�1 Other 11 Delta Depth of Grout Seal Type of Grout r� I I Irrigation /d / Approt. Depth I I Eastern Surface Seal Installed by ^3 Repair Work Done U Type of Pump H.P. Stare Work Done _ Well Destruction Well Diameter Z T4 Sealing Material & Depth Q Depth 7g O Filler Material & Depth W TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION i I ,DESTRUCTION I I ;No septic system permitted it public sewer is available within 200 teat.? }ty� Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of coil 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. b Length of lines Total length/size FILTER BED © Distance to nearest: Well Foundation Property Line SEEPAGE PIT'S 11 Depth Size Number SUMPS Ll 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 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 applicaqt4qst fcall for ail required inspgetions. Complete drawing'on reverse side. Signed �`'� Title: /dam_ Gr,!/ ie/N� �L. Date: A4 1,64_ G. GRLe G+EJp/ A- A-A ENFrt W&,6,e,0v& /NC.. FOR DEPARTMENT USE ONLY // ) Application Aeeapted by Date f0 Z a Area L•,�� Pit or Grout Inspection by f y Date Final Inspection by -Date S Additional Comnwnta '` •- -37-3 z Z M� •,(mac..... Applicant: — etur4 all Copies to: Sao Joaquin County Public Health Services A (� Environmental Health Permit/Services 445 N San Joaquin. P 0 Box 2009, Stkn. CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY INFO GASH DATE PERMIT•NO. EH t3.24(REV,r/aJr y EH 142E 612 9� D3tyz