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SQOAQUIN COUNTY. PUBLIC ,HEAL' SERVICES ENVIRONMENTAL HEALTH DIV ON 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 medeqto San Joaquin County for a permit to construct and/or insts.11 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 Servicess.1� Imo( p)KT CP!/M11� City h dLoi Slze/Acreage Job Address Je0 _ _T'k �n Address32-7 onsorr. ` ifey 7�1 by-) pnpne 2o'I 5`1R-3 58 Owner's Nam _„ 1 1',�eM r� 4400 C>iS-h-tC l-1 B)vd &5)331 ry^ Contractor• l� Fhcnn .�Q?�PYi IVY_ ddress BgIIGV•'SrrtelCS 4, SDt/ „ 'License No. Z53 qZ Phan' 5 `b3 IQd TYPE OF WELL/PUMP: NEW WELL O WELL REP tACEMENT n DESTRUCTION O Out of Service well Ll �, •Monitoring well PUMP INSTALLATION O SYSTEM REPAIR C OTHER 5011.dCKt 065 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES �V/ DISPOSAL fLO. _ PROP. LINE, 50 FOUNDATION z0! AGRICULTURE WELL OTHER WELL IO6v4s, PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS -1 'C industrial ❑.Open Bortom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑�etGravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public F O her n Delta Depth of Grout Seal Type of Grout II Irrigation °Approa. Depth I I Eastern Surface Soul Installed by .Repair Work Done (7 Type of Pump H.P. State Work Done _ Well Destruction O Well,�,Diamster Sealing Material i Depth TYSut ftolu-4s Depth Piller Material L Depth E OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION I I DESTRUCTION I I (No mpiic system permitted If public sower is available within 200 feet.) 1 Installation will serve: Residence_ Commercial_ Other 1 Number of living units: Number of bedrooms �. Character of and to a depth 'f 3 leer: Water table depth SEPTIC TANK ❑ T Mfg Capacity No. Compartments �PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line 'LEACHING LINE O . 6 Length of lines Total length/size c FILTER BED O Dist is to nearest: Well Foundation Property Line t SEEPAGE PITS I I pth Size Number 'SUMPS LI Ois[ to to nearest: -Well Foundation Property Line 'iOISPOSAL 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 suc-contracting signature certifies the following: "I canitylthat in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa tion lows of California." /J The appftcan ust can for an town Spections. Complete drawing on reverse side. 1 -712 z �93 "Signed Title: A6eu'r �e�I{lu�/AnJA1j /GE Date: q FOR DEPARTMENT USE ONLY �1 G? S_1 Z 1• D 1. Application Accepted by , V� Date Y•2� • /J Area �i✓ll� Pit or Grout Inspection by -' - - Date Final Inspection by rOyatts P 10-L Additional Comments. rOCt i Bort✓1G 'S (furl" WEALS (Ha)l r114e-tU41 .2p t�,ay-lA14 12 i 4 r CAD he%3 Applicant - Return all copies to: San Joaquin County Public Health ServicesI,,gbp..glrll w Environmental Health Permit/Services _ IU/ 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE I AMOUNT DUE AMOVNT REMITTEO CK RECEIVED BY GATE PERMITNO. INFO y��fs �}f'E{ CASH . EHis-zalREv.ii.sr WM UY 89 `�'- �� --- 901 I MM �-2.13 1 {58, EH ib]a