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I� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES VX � �y S - ENVIRONMENTAL HEALTH DIVISION - I 445 N .SAN JOAQUIN, PHONE (209)46$-3420 q ,�'Db , 1., _ 1 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) V - � -� 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public! Health Services. Job Address 4 7 5 0 S Jack Tone Rodd Stockton City Lot Size/Acreage 100 Owner's Name Al�o TOgninali Address 14500 E. Hwy 4 , Stockton___ Phone Contractor-Pl rV]Tli� i71a� IIIc. Addresses 64,I�lndaz, C5 License No,377923 Phone 887-3554 TYPE OF WELL/PUMP: NEW WELL 7 WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well ❑ II PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 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 �-'- ❑ Industrial ��0 Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing 16 ['I Domestic/Private 1110 Gravel Pack ❑ Tracy Type of Casing_ Steel Specifications •250 ._ Il Public !1 FI Other n Delta Depth of Grout Seal 224 r Type of Grout CeTen5ae- I Irrigation 400 Approx. Depth I I Eastern Surface Seal Installed by 1 ZZ Repair Work Done ❑ jType of Pump H.P. State Work Done Well Destruction ❑ 'Well Diameter Sealing Nateerial A Depth JDepth Filler Material A Depth TYPE OF SEPTIC WORK:, NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is { available within 200 feet.) `J Installation will serve: Residence_ Commercial_ Other I 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. Ct -- Method of Disposal 11 Distance to nearest: Well Foundation Property-Line I LEACHING LINE GI No. A Length of lines Total length/size: F FILTER BED n Distance to nearest: Well Foundation Property Line .i SEEPAGE PITS Id Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C] 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 suchimanner 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." 0 The ap ant m s call f ` I r uir inspections. Complete drawing on verse std , M2 / Signed �� Title: Date: rA IN` FOR-DEPARTMENT USE ONLY Application Accepted by '! Date h 13'2!k Area Pit orrout spection byl� Date tL q7— Final Inspection by Date Additional Comments: ' GA4 WA 5,�;M,4 Applicant - Return all copies to: San Joaquin C my Public Health Services 1 Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED Ely /DATE PERrWVN0. . EK13-24(REV.I i x si � 173 �� /� ✓ EH 71-2e V ' I�