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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-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 conipliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servs es. QQ r Job Address 1 v `-" E , CiIYAJt Lot Size/Acreage Owner's Name AddressA�raIK�-A � Phone 3(08-s ' C'o P.� �rnc?67 (P9-sr Contract Address .+ License No. 2�z ZOO Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Q Monitoring Well ❑ DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL . PITS/SUMPS - \ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom C) Manteca Dia. of Well Excavation Dia. of Well Casing C� to Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications [� I"1 Public Cl Other 1"1 Delta Depth of Grout Seal Type of Grout I i Irrigation _ Approx. Depth I 1 Eastern Surface Seal installed by Repair Work Done U Type of Pump H,P. State Work Done h Well Destruction ❑ Well Diameter .- Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I iREPAIR ADDITION DESTRUCTION I I (No septic system permitted it public sewer is ^ / available within 200 feet.) ,\ Installation will serve: Re idence Y Commercial_ Other h Number Of living units: Number of bed s A Character of soil to a depth of 3 feet: Water table depth �d SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments Y PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITSDepth Size Nymber �7 r SUMPS UI Distance to nearest: Well �UD Foundation 0 Property Line__ S 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 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 st call fO re ' ed inspections. Complete drawing on reverse sid Signed X Title: Date: J021r 0FOR DEPARTMENT USE ONLY Application Accepted byDate Z Aran r4 Grout Inspection by ate( -71��'9**nel Inspection by —CSC_ pate 44/Z n rl Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O'Box 2009, Stkn, CA 95201 FEEINFO AMOUN,TnnDUE AMOUNT REMITTED GK ECEIVED BY DATE PERMIT NO. . Ek 13-24 IREV.t i A51 0 EH 14.26