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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 aonpliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job AddressNEWOIAAXLE� ROAD City SUiVXW Lot Size/Acreage Owner's Name 1C- CA int 1 C��Address ��A�G SZ/S�' Phone W- �. 4!Mr_) iytrnvT Contfactor&ACk PUM42 a4aAddress License No..V4r/3 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ out of Service Well ❑ PUMP INSTALLATION f<11 t 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 1J INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f y n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing W (,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications ^. i'1 Public fa Other Fl Delta Depth of Grout Seal Type of Grout i I Irrigation _'Approx. Depth l I Eastern Surface Seal Installed by A Repair Work Done U Type of Pump � H.P. � �6 J4 JO State Work Done % ��f . - rll CX4 v Well Destruction ❑ Well Diameter Sealing Material & Depth f aC49142. GJ'4 -;-14 Depth Filler Material & Depth „ A J& U tiC-r TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 leet.l FT]Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation - Property Line LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS 11 Depth Size Number rf SUMPS Ll Distance to nearest: Well Foundation Property Line 1 J 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 cirtifies the following: "I certify that in the performance of the work for which this permit is issued, I shalt not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-gontracting 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." l The applicant mus all for all required insPections. Complete drawing on revers s'do, ` C� Signed X Title: Date: le—Z f 2, F DEP RTMENT USE ONLY Application Accepted by -4 MA Date `L /Area — t 14 Pit or Grout inspection by Date Final Inspection by Data -� Additional Comments: 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK I RECEIVED BY DATE PERMIT'NO. ) . £H t3-26 iREV.liHSi 0o � .0 o S ls—l/ EH 14•26 �