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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES l 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) i 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 L Joaquin County Public Health Services.. �,1 Job Address _17Q _ ✓A/!-OLl/ City �� `�'a Lot Size/Acreage Owner's Name 0340A r7tA Zw<�� Address Phone Contractor 4IfA [.Glr Address AoqW 17401" Licen`se P46.'J77J�'r Phone -Y?u j TYPE OF WELL/PUMP: NEW WELL ❑ i WELL REPLACEMENT5W DESTRUCTION C1 Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR 0 OTHER c Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK !a SEWER LINES DISPOSAL FLO.Z.12 PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL, rM PITS/SUMPS T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F] Industrial ❑ 0{ion Bottom ❑ Manteca Dia. of Well Excavation &4 IL Dia. of Well Casing t _,LYDomestic/Private Gravel Pack ❑ Tracy ; Type of Casing_ QVC Specifications i'1 Public I-1 Other ❑ Delta ! Depth of Grout Seal Type of Grout C � _ I I Irrigation L4a Approx. Depth I I Eastern Surface Seal Installed by, 9.t21_-MIA 7°%4 Repair Work Done L] Type sof Pump __.�' H.P. l ✓ *t$tate Work Done _. A- sem_ Weil Destruction ❑ Well Diameter Sealing Material & Depth e a Depth�tl Filler Material & Depth � T,YPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is ^� available within 200;feet.) Es.1 Installation will serve: Residence� Commerciale_ Other •',,,� r` �' Number of living units: I Number of bedrooms €{ Character of soil to a depth ofj'3 feet: •` .g t Water table depth SEPTIC TANK ❑ Type/Mfg / Capacity No—Compartments PKG. TREATMENT PLT. ❑ I� l f Method;of Disposal Distance to nearest:` Well Foundation Property Line I r\v t LEACHING LINE C1 Wo & Length of lines f Total length/sire ' FILTER BED 0 Distance to nearest: Well Foundation Property Line1-7 +< E ' I SEEPAGE PITS II Depth P Size Number _.- SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL 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 Son-J.1 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- I tion taws of California." `p� { The applicant must II for li required insPections. Complete drawing on reverse side. Signed Title: Date: 7 2-9-1�" OR EPARTMENT USE ONLY ►s n ` Application Accepted by� Date —_7-C 1 LZ Area Pk or rot Inspectio tf19 Dae ' 2 Final Inspection bye 4 - Dat Additional Comment . a, JN a0k Applicant - Return all copies to: San Joaquin County"PublicHealth Services Environmental Health Permit/Services •, r k 495 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNTIDUE AMOUNT REMITTED CA$ RECEIVES BY SATE PERMIT'NO. wit xr + EH 13.24IREV.It"51 EH 1L26 I� YJ