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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95203. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Complete in Triplicate) ,l®�d/d - Application in hereby made to San oa uin unty for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 4!4 Job Address W CQ n 8021,PnrLd 4 CiryLaJh_,g.07a__ Lot Size%Acreage Owner's Name f Address'd 0 E• L O L[�S e ------ Phone 8 5 8-5 51 ContractorUGI - b2 e Address 2024 E. LiCense No3210 Phone_A.6 TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT !1 [IESTRUCTION_t'�aut of service Well 0 / PUMP INSTALLATION El SYSTEM REPAIR 0 OTHER C1 Monitoring tell �J 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 n Industrial ❑ Open Bottom CI Manteca Dia. of Well Excavation Dia. of Wail Casing El Domestic/Private Cl Gravel Pack L1 Tracy Type of Casing__— Specifications --� I•I Public Cl Other fl Delta Depth of Grout Sea€ __. _ Type of Grout I I Irrigation _Approx. Depth I 1 Eastern Surface Seel Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction xQx Well Diameter __9� Sealing Material b Depth X77 2 � Y_o -5 0 Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRrADDtTION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.l Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feat: ____Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length;size FILTER BED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size _ Number " SUMPS Ll Distance to pearest: Well Foundation Property line DISPOSAL PONDS Cl 1 I hereby certify that I have prepared this application and that the work wilt be done in accordance with San Joaquin county ordinances, state laws, 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 all for II r ed 'n tion mpl drawing on reverse side. Signed X Title: V1 Cia2k Vetg, Inc Date: FOR DEPARTMENT USE ONLY _ Application Accepted by Date --P.--_ Ar ;2 _ aa Pit or Grout Inspection by Date Final spection b Date s �1 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 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'N0. �IIN)F�O] /�/y CASH EH 13-24 IR EV.tiKsl f��L/ VV i EH 14.29