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CPO ADPL IC_"M10 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) 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 Coun y DZ-,-,. No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. l�1: 1 � � r �, �aw�--�rs.r_ �Ir, LOD ( Lot Size/Acreage _t 06 JUU Owner's Name (ego 1 AWnJtQAW� 60KF. Address Z11O WalytA Hill S,i1 - 26.0 Phone Zrv11111 ,Te)ea5 75_036 Contractor NJNT 'DCQ1Wt_.)6 (,O. JK)C_ Address t?0 BOX 1 LZI , TACXS(W ,-,A License No. 5(,3952- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 7 DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 504 801rr63 OTHER X Monitoring Well 17 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL14n, PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C.l Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing_ OW4E Specifications L I'I Public Other n Delta Depth of Grout Seal 35/ Type of Groutceynw+ r I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done Ll Type of Pump H.P. State WoQrk Done _ Well Destruction C3 Well Diameter Sealing Material & Depth C -e- M't" 35 r SO1l 'C111 Depth Filler Material & Depth 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 1 11.1 Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: y_Watef table depth SEPTIC TANK ❑ Type/Mfg Capacity "I DCgnpartments PKG. TREATMENT PLT. ❑ letF1� Oitl#osal Distance to nearest: Well Foundation Pr�R� LEACHING LINE Cl No. & Length of lines Total�Asize FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 must call for all ,required inspections. Complete drawing on reverse side.. �1 Signed X P -� "�— Title: (f01 Cil 6dot!N l5+ Date: t to Application Accepted by Pit or Grout Inspection by Additional Comments: FOR DEPARTMENT USE ONLY Date Area e .l Final Inspection by 1 Date Applicant - Return all copies to: San Joaquin County Public Health Servi J Environmental Health Permit/Services) V ' 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 J • EN 1324 (REV. i i M 5) EH tt-2e FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK i RECEIVED BY DATE PERMIT' NO. �6."