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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES j� ENVIRONMENTAL HEALTH DIVISION 4F 445 N SAN JOAQUIN,, .PHONE (209)468-3420 P O BOX -2009; STOCKTON, CA 95201 • s ? , 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 County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. -rlve Job Address "- I E Maem R) City i. Lot Size/Acreage Owner's Namebb¢t Mo-le,Cwc1e- Cl►i-lo Address 59?40r Mia tAa l�q. Phone 914Z Conlractor 3 •4 -jAndress © '_Q 1c �q 2 1 License too, Z3� Y Phone Gz TYPE OF WELL/PUMP: NEW WELL ❑ / WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Nell Cl / PUMP INSTALLATION SYSTEM REPAIR 0 OTHER p Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE - - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` ts--�V .INTENDED USE ,ti TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Industrial �J.. " ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I] Domes` s0 Private' ❑ Gravel Pack e L] Tracy Type of Casing_ Specifications I'i;Public I:1 Other ❑ Delta Depth of Grout Seal Type of Grout I I Irrigation _,Approx. 0 th I I Eastern Surfs a Seal Installed by -�7 t Repair Work Done Type of Pump;qtr' I tr1e. H,P. ^ �' ��s� State,Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth <' # ` Depth Filler Material 8 Depth ''- jTYPE OF SEPTIC WORK:.lNEW INSTALLATION I I REPAIR/ADDITION ('.J DESTRUCTION l 1 (No septic system permitted-it public sewer is -available within 200 feet.) Installation will server .Rtfsidence—_ Gom erciat�..�Other—• ��- �� • '� .......................... t Number of living units: Number of bed ms Y f Character of&oil to a depth of 3 feet: r Water table depth SEPTIC TANK. . ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1 Method of Disposal 11'y Distance to nearest: Well Foundation Property Line 1 J�LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED L'1 Distance to nearest: II Foundation Property Line , r � . SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to Weare Well Fou n tion Property Line DISPOSAL PONDS ❑ I hereby certify that-) have prepared this a6 liCation and that the work will be done in accordance with San Joaquin county ordinances, state laws, and eulsi -and-regulations-of the-Son-Joaquin County Home owner n agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not employ any raon in nuc manner as to becom bject to workman's compensation laws of California." Contractor's hiring or sub contracting signature certifies thfollowing: "f C ify that in the per rm nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion Iowa f California." The app) ant m t or all r u' �plete on v se d Signed X Title: Date: EPARTMENT USE ONLY C72 Application Accepted by A., L Date _._ Area�f Pit or Grout Inspection by Date Final Inspection by Date2 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health mit/Services 445 N San Joaquin O ox 2 69, Stkn, CA 95201 IF O EE AMOUNT DUE MOUNT REMITTED CA RECEIVED BY ATE PERMIT'NO. . EH 13.241REv,vksl YaAP7 FH 1 .7,6 /