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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) ?qg— � `f0—T(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 y1th San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public-Health-Services. I Job Address ?� ,z �6r n Rowland city l rr�h a 0.p Lot Size/Acreage Owner's NameU f Address5 G L O Phone 858-5151 ContraciorCL21k' Vf—i-4 Address 2024 6,__C&ar i-.tv_-12 __ License NO71 5 h 0 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION EkOut of Service well ❑ ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL. FLU. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing [:1 DomesticlPrivate C] Gravel Pack q Tracy Type of Casing Specifications Il Public C7 Other n Delta Depth of Grout Seal Type of Grout Q , I I Irrigation —.App(ox. Depth I I Eastern Surface Seal Installed by ] j Repair Work Done 0 Type of Pump H.P. State Work Dane „ Well Destruction xZ)c Well Diameter 9 Q' Sealing Material t. Depth a_r, v n f 1 n v .Q o n h f p -50 Depth Filler Material b Depth Q ACI,,k.-_6-0}-Lw„, i„ 4„ n TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Numbef of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg j Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE L1 No. & Length of lines Total length/size FILTER HED ❑ Distance to nearest: Well Foundation Property Line I SEEPAGE PITS 11 Depth Size Number SUMPS LI 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, an 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, t 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 all for II r ed 'n tion mpl drawing on reverse side. �r Signed X Title: VP C. a zk Ilzi-Q, Zr Date: 17 �nn 9 3 r, FOR DEPARTMENT USE ONLY Application Accepted byAlcData �/ /- —�- Area a;2/1? Pit or Grout Inspection by ate ,f F'nal Inspec 'a by 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 85201 FEE )NFO AMOUNT/DUE AMOUNT REMITTED CASH CK S RECEIVED BY DATE PERM17'NO. • EM 13-24 fRt:V,fiN51 vv EH t/.2e