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A PPL•I C'l't'T ON 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 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 Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. .r4 ♦,�r��RJ. s�b ��4 � � rill Job Addres " � — Tk��^� City Th'b^a�� Lot Size/Acreage acj�:c (74i t E1e,+-r•z '(_r r__y Owner's Name �7t re1u bn+-S-&L. Address 3 -u_W�C+ J`apers"'ituo (AWI 4 i YAC Phone 0 Contractor _6c-ftj a'ts{'' &P+' Address214Clbseu','ie I MOL A Ccm- License No.l-37,1(02-5 PhoneLe9-3L'7-421.8 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER`SLPI°p1�'IrgsxCis) O DISTANCE TO NEAREST: SEPTIC TANK WO-2 SEWER LINES "'PIC DISPOSAL FLD. PROP. LINE '— AAA i r o a o�— FOUNDATION ti+^� AGRICULTURE WELL NeNe OTHER WELL/+r+ ,•./- PITS/SUMPS�`✓•"S INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I"1 Public Cl OtherDepth of Grout Seal Type of Grout *1_J Imfxr,�,,Yah (tf) — Approx. Depth I I Eastern Surface Seal Installed by .pair Work one UType of Pump H.P. State Work Done _ ',enwS IT_ Sealing Material i Depth /41�14;t_ Ce_~,►f-y/S N. t k O—/L{4. Well Destruction ❑ WeH Diameter Depth 9 —12 -F#. Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo 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 soil 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 Foun ton Property Line LEACHING LINE 0 No. fi Length of lines Total length/size FILTER BED ❑ Distance to_Aeaiest: ikell Foundation Property Line SEEPAGE PITS I I' Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line D;;OOSAL PONDS ❑ 1 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 applicant mu call fo II wired inspgctions. Complete drawing on reve�r side`. /�f ,/� f Signed Title: / �mz ��/� Date: Q4? /" FOR D PARTMENT USE ONLY �} 0 Application Accepted by �l c LG Date � Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments. ` `4. Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services � J 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 , r FEE INFO AMOUNT DUE AMOUNT REMITTED CK f ASH RECEIVED BY DATE PERM I O. . EH13.24IREV.rills � / OD y / . OD IIZ- f l L1✓ 1'�p :/t EH t/-2e l G/ 1 !!