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SAN ")AQUIN COUNTY PUBLIC HEALTU t:RVICES 'I ENVIRONMENTAL HEALTH D I V I S.—,ii 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 No. 5149 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address LI)I I AOn L1114V City S+c)c `40e) Lot Size/Acreage 11 T —-- c ) Owner's Name 1�-�a�j `or02g,a1;c'n Address '7y! N 11 131acr s4-rle duc. Phone 6ZO -yayo RIF Contractor /re l.'Orl.iu/kP4 Address ._0q0 Ckrrem 64 0f. License No. S/a0/O Phone 619-Z?f-6;" .? TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT (-1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATIONSYSTEM REPAIR Cl OTH�R O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK o` of SEWER LINES �/60 A-f DISPOSAL FLD. X00 +PROP. LINE ZLU{'tea 1 FOUNDATION 0{'•e AGRICULTURE WELL /�OTHER WELL 50Pre PITS/SUMPS 1`-)14 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS // n fl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation s- Dia. of Well Casing iroh a . XDomestic/Private Gravel Pack* ❑ Trac Type of Casing ,� y yp g Q d�c•_SC'Nr�`lO C Specifications I'1 Public II Other 11 Delta Depth of Grout Seal — Pee-+ __ Type of Grout I I Itrioation r_ Approx. Depth I I Eastern Surface Seal Installed by /r rl"J.I><4 Repair Work Done ❑ Type of Pump N-19. H.P. N State Work Done Well Destruction ❑ Well Diameter �gllY�1GG�� Sealing Material i DepthRe-1 fe„,'�f- d - 70f,-e+ Depth 201s ref Filler Material i Depth #,Y S9NQ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DEST �TJQ[J I I (No septic system permitted it public sewer is PIMEF" within 200 feet.) Installation will serve: Residence Commercial Other RECEIVE \ Number of living units: Number of bedrooms RECEIVED `\ Character of toil to a depth of 3 feet: MAY I O 199 Water table depth SEPTIC TANK ❑ Type/Mfg CASAA N-io. Compartments PKG. TREATMENT PLT. ElPURLIC HEALTH SERVIdo[�od of Disposal ENVIRONMENTAL HEA(pTrHpMfulUfi 6 Distance to nearest: Well Foundation LEACHING LINE Ll No. b Length of lines _ Total length/size FILTER BED 1:1 Distance to nearest: Well Foundation Property Line ^ �� SEEPAGE PITS 11 Depth __ Size Number 4 SUMPS 1.1 Distance to nearest: Well Foundation Property Line DISPOSAL 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 workmen'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 ompensa tion laws of California." The applicant must call for a re s n"omplete drawing on reverse/side. Signed Title: Pre 9;d, ✓)+ Date: 9 FOR DEPARTMENT USE ONLY -11-13 �j Application Accepted by f 7t GL 1 -yL Date y Area Pit or Grout Inspection by / Date Final Inspection by Date Additional Comments: Applicnnt - Return all copies to: San Joaquin County Public Health Services /_ q, Environmental Health Permit/Services Ij 445 N San Joaquin, P 0 Box 2009, Stkn, CA 9520CK 0FEE / INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 8V LOATE PERMIT NO. 7 EH I .N INEV.rrAsr •1�L -4 �;', -kz,f'71 c - l-Y� fH t4Ie