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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Sam 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 2VYoo S FmokKks Qd City__& Lot Size/Acreage.2-Sor 7��/ 7/�oel' Owner's Name �� N V Bek Address SAMe Phone Contractor .- �ha. i !�AGjLaC Address �So 8UrTbM A(&nse No.293916 Phone 82'3 .65e TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L) OTHER ❑ Monitoring Well DISTANCE TO NEAREST_: SEPTIC TANK $EWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Dorb6stic/Pfivate ❑ Gravel Pack — ❑ Tracy Type of Casing_ Specifications \1 I.1 Public fa Other --T-1 Delta Depth of Grout Seal Type of Grout �(v� I I Irrigation Approx. Depth 11 Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material A Depth (� Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will )live: IResidence commercial _ her Number of living units: Number of ooms Character of soli to a depth of 3 feet: --- ANDY Water table depth SEPTIC TANK; ❑ Type/Mfg .. Capacity 1:2 V e No. Compartments PKG. TREAtMW PLT. 0 t r , Method of Dispsal Distance to nearest: Well J J Foundation S Property Line 6 LEACHING LINE No. 11 Length of lines O Total lbngth/size d FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I Depth Size Number UMPS LI Distance to nearest: Well 7U, Foundation U r Property Line 1c) _ DISPOSAL PONDS ❑ 1 hereby cortify'that I have prepared this application and that the work will ft.,done in accordance with San Joaquin county ordinances, state laws, and rules and rogulltions of the San Joaquin County - Home owner of licensed agent's signature certifie the following: "I certify that In the performance of the work for which this permit is issued, I shall not employ any portion in such manner as to become ubject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the follbwino: "I certify that in the perfo ante of the work for which this permit is issued, I shall employ Oersons subject to workman's compensa- tion laws of California." The applicant dw for all r d Inspe. one. Complete drawing on reverse side. Signed X Title: Date: y .3 (707 t FOR DEPARtMENT USE ONLY i Application Accepted bytk Dille — ea d Pit or Grout Indpection by Date Final Inspection b r Date Additional Comments: 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 INF AMOUNT DUE AMOUNT RREMITTED ��K. RECEIVED BY DATE PERMIT'NO. EM 1]-21111EV.miRSl / r0� "' EH t1-2e