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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I+ ENVIRONMENTAL HEALTH DIVISION 1 445 N SAN JOAQUIN, PHONE (209)468-3420 1 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 madg in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health S'erv/Oi�cl/es/. //_/�) Job Address / �6 V" k ole, L ' City ' Lot Size/Acreage Owner's Name DA,n10� Sa'n`er"`^"7—Address 1?0 tj Phone Contractor ' sar� Address �' "�� ife- a_n License No. Phone 1`� 1�� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service well PUMP INSTALLATION OSYSTEM REPAIR ❑- OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL— PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing C:l Domestic/Private O Gravel Pack q Tracy Type of Casing_ Specifications I'I Public Cl Other n Delta Depth of Grout Seal Type of Grout 11 Irrigation —Approx. Depth • 1 1 Eastern Surface Seal Installed by U Repair Work Done L3 Type of Pump H.P. State Work`Oone_ Well Destruction O Well Diameter Sealing Material &,Depth Depth' ! . Filler Material & Depth TYPE OF SEPTIC,WORK: ,,NEW INSTALLATION I I ,REPAIR/ADDITION,I I .DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other y Number of livingtiriits: ' Number of'bed►ooms { � -"'— --�-j -� ------ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartmerlts PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: Well Foundation - Property Line t LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size6 4 Number SUMPS LI Distance to nearest: Well Foundation Property Line t DISPOSAL PONDS O 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 st call for all re u'ed inspections. Complete drawing or�ne,reverse side. S X Title: Vu�r�e� ' \ Date: — F ONLY Application Accepted by r Date —97— Area _ Pit or Grout Inspection by L Date Final Inspection by Date Additional Comments: (�/ " 4,, C rticaco ftt -- 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 I CA RECEIVED BY DATE PERMIT'NO. INF/Ory') ,� / ,s CASH �( q . . EN 13.211REV.�inS� wV a♦s� tf�-� °�V t�� -4c� . q2 (1 EH 11.2a