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SAN JOAQUIN COUNTY. PUBLIC HEALTH SERVICES j 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 Sen Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I , Job Address 5 7 b Z 1 ti L City .,4 1, �o , Lot Size/Acreage Owner's Name Edyincy_n�t Address Phone 5 Contractor U a, k NP-Le, Inc Address 2n74 E. Cha/ teri License No. 379560Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ZkOut of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL Ff_D. PROP. LINE is FOUNDATION AGRICULTURE WELL OTHER WELL. PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS \ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing f"I Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications f'1 Public f_1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation __Approx. Depth I i Eastern Surface Seal I e by .; Repair Work Done 0 Type of Pump H.P. State Work Done Walt Destruction Aa Well Diameter 6n Sealing Material Depth 90�iala 4- 49P -- Depth 9 1 7 Filler Material a n,t TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION ( I DESTRUCTIO INo septic sys rc sewer is a le within 200 feet.) # Installation will serve: Residence�.,.. Commercial ____.. Other Number of living units: Number of bedrooms fa Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal k Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Weil Foundation Property Line 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, 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 t a I ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant f I it ins ti mplete drawing on reverse side. Signed Tide: VP UglLk biaZL Inc. Date: FOR DEP TMENT USE ONLY ll Application Accepted by Ah Date Pit or Grout Inspection by Date Final Inspection b Date- Additional Comments. l Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO, INFO ♦ CH 13.24(REV.I I K51 WD 100.0 Q cOD �+� D ' �i D EH 14.2e