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SAN IJOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION rorr3 ©-- 1006-07 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 L,/634y_OW044-5— ft" PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i; (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 compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. + W Job Address Soo iz, ft,TS E city ' �1 'mJlo _ Lot Size/Acreage `` Owner's Name 41AA 0VJ,,�N.5 Address iB Phone Contractor.�P lh Y4_64NAeL ess 2-e2-S- JE, MYfL7Y4F- 5r License No,92-ZAS_ _Phone_5YJY-13 TYPE Of WELL/PUMP: NEW IWELL ❑ WELL REPLACEMENT ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DISTANCE TO NEAREST; SEPTIC TANK i I SEWER LINES DISPOSAL FLO. fes— ,gp(L/ ( I FOUNDATION AGRICULTURE WELL OTHER WELL P1TSF&6Nw4F1S—T INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I� n industrial _ ❑ Open Bottom ❑ Manteca Dia. of Well Excavation C) Domestic/Private ❑ Gravel Pack*! ❑ Tracy Type of Casing_ 5padf+eas+eat: I'1 Public CI Other F1 Delta Depth of Grout Seal def-Ccaw� I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by f-u! Repair Work Done 0 Type of Pump I H.P. State Work Done_ d t=N2aN1)7z O LS Well Destruction 0 Well Diameter Sealing Material & Depth Ic Depth f Filler Material & Depth r TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is J j available within 200 feet.1 Installation will serve: Residence_ 'Commercial.— Other ff ` Number of living units: Number}of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG, TREATMENT PLT. ❑ ,y Method of Disposal Distance to nearest: Well Foundation Property Line 1 � LEACHING LINE 0 No. & Length*of lines Total length/size { FILTER BED n Distance to nearest: Well Foundation Property Line I I No SEEPAGE PITS 11 Depth r Size Number Q SUMPS CI .Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I i 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 6enifies 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 taws 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 must call for all required inspections. Complete drawing on reverse side. Signed X Title: .,_9Fl-J6 16#01-06.157— Date: IF DEPARTMENT USE ONLY Application Accepted by Date '~ AiWa Pit or Grout Inspection by Da Final Inspection by Date Additional Comments: �► -4 r Q Applicant - Return all copies to: San Joaquin County Public Health Services J;._.o3y 7- Environmental Health Permit/Services 445-N San Joaquin, P 0 Box 2009, Stkn, CA 95201 IFEE N 0 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. + EHti•24IREV.I/R51 E 71-20 7 , ° bat /- 9-� .� '� H o