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i' SAN UIN COUNTY PUBLIC HEALTH MVICES Qb_ z4 VIRONMENTAL HEALTH DIVISI 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 v r PERMIT E%PIRES 1 YEAR FROM DATE IS I�II"17 (Complete in Triplicate) kL4 Application is hereby made to San Joaquin County for a permit to construct and/or insta 1 the work herein de ibed. This application 1s made in compliance with San Joaquin County Ordinance No. 5149 and 1862 and 1h41"stxtg ulatlons of San Joaquin County Public Health Services.Ave— Ylhhll�C(( ��LL c Job Address `1� t 6. Slorlto � / City �(pvl iz Ac ea e� Owner's Name s t w pse)n f AttCe-Ir l ) Address l 60A 757, Cox, CA 9.S MITT one `-4241 ContfactoilLAW�'i D&Lj��v�Addres,zooI("Wt�lCl -Lice No. 1_ Pho e2F`F q 1&3 TYPE OF WELL/PUMP: NEW WELL lW_ WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service Well Cl PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well Xr DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 5c'_,G ric3 Industrial C1 Open Bottom O Manteca Dia. of Well Excavation -ST 1nG� Dia. of Well Casing Cl Domestic/Private XGfavel Pack ❑ Tracy Type of Casing_PVC- Specifications Il Public 1-11 Ota, / gt,, n Delta Depth of Grout Seal �___ Type of Grou4 1/v I I Irrigation U� A ox, epth I I Eastern Surface Seal Installed by �.va rare' Repair Work Done 0 Type of Pump H.P. State Work Done _ Well D truction O Well Diameter Sealing Material & Depth O / Depth Filler Material & 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 Character of toll to a depth of 3 feet: Water table depth_ SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. b Length of lines Total length/size oft FILTER BED Cl Distance to nearest: Well Foundation Property Line PA'MNT SEEPAGE PITS 11 Depth Size — NumberMAD �- 1992 SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS OPiTn�YNUIN COUNTY I hereby certify that I have prepared this application and that the work will be done in accordance with San UA jWt eNr�g( , -1 and rules and regulations of the San Joaquin County Prfir }I IVISION 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 X /.GY� Title: `Z>�[DSrI S 7 Date: �L FOR DEPARTMENT USE ONLY Application Accepted by CAA� Date2- 1 Area 01. Pito �, unspection by Date Final Inspection by Datd� Additional 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 CK CASH(/ RECEIVED BY DATE PERMIT'NO. EH 13 24• EH 14 20 IREV.iix51 t'' CI 0