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SAN JJRUIN COUNTY PUBLIC HEALTH 3&ICES T' `—� VIRONMENTAL HEALTH DIVISIOAW 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 M PERMIT EXPIRES 1 YEAR FROM DATE ISSU (Complete in Triplicate) I nnnnnn� c� 11 QQ�� Application is hereby made.to San Joaquin County for a permit to construct and/or install thdY PA tae4il9dUcribed. This application is made in coupliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address L14 S, S4�,c.k- Q� E�VIROa�NME AL HEALTH Z City P_0_n _ Lot i �a _ Owner's Nam SO 'Ir Address R —CAA-5-3U.� P one 53•-44 � ContraclorlA .lMCrl-R�� 0-1441 C"P one W -9 {jti1N �l�('L� AVIriC�Address License No. TYPE OF WELL/PUMP: NEW WELL Vd WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well PUMP INSTALLATION O SYSTEM REPAIR Cl OTHER O 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.SC's t7IV Ve_ 3 V-Industrial O Open Bottom O Manteca Dia. of Well Excavation -5 Dia. of Well Casing Cl Domestic/Private MGravel Pack ❑ Tracy Type of Casing _ Specifications -ti 4-0 Il Public I:1 Other FI Delta Depth of Grout Seal — -21's� Type of Grout YIfftf Ylle"'L7 I I Irrigation g' 25-12 Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth (1 Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Cn Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. U Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. d Length of lines Total length/size_ FILTER BED ❑ Distance to nearest: Well Foundation Property Line el SEEPAGE PITS 11 Depth Size _ Number AN 2 C SUMPS I._I Distance to nearest: Well Foundation Property Lirml1C �N Q DISPOSAL PONDS a > At rH C R NTY I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, t Lf", d rules and regulations of the San Joaquin County J arl 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 inssPections. Complete drawing /on�reverse side. Signed X / �641t Title: i2 ` �� Date: Z F ARTMENT USE ONLY Application Accepted by CiNc.J%I" __cT1 Date J' ay' \ �- Area C) L V Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public flealth Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED ` CK RECEIVED BY DATE PERMIT NO. INFO q CASH /IV DATE OPER �(O. • EH t1.�IREV.rinsr (� l'0 �9 .(��