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wK ri SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION i� 445 N SAN JOAQUIN, PHONE (209)468-3420 ,t-X +Y7 2073974-02- P 0-3974-02- P O BOX 2009, STOCKTON, CA 95201 �1Fi2.rz.�1- 1+7LL-5 PERMIT EXPIRES . 1 YEAR FROM DATE ISSUED u (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. Job Address /L-f4 i20 City 4 �KFaIJ Lot Size/Acreage Cyd r� Owner's Name�� & viddress �7`}'p'1I I� _ Phone ContractarSPF1�77�.C1t'1 i�+� d ss ZR�2--T iffr m�Mr/!E 5r License No._,VIZ7-66 Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT (7 DESTRUCTiv' E 9d1h of ii PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ' , DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. I FOUNDATION AGRICULTURE WELL OTHER WELL 9'4FGt9t7T 'S-- If ©j i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (� Zoj n Industrial „© Open Bottom ❑ Manteca Dia. of Well Excavation C1 Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing_ -SpeciimCariag Wo- C` i'1 Public L] Other n Delta Depth of Grout Seal 3 p�af-Gf-� I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by E'vrGC. u3/ Repair Work Done 0 Type of Pump H.P. State Work Done i10W.6 a AJ6 N ,r— Well Destruction ❑ 1°Well Diameter Sealing Material 6 Depth /to aro © r Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is ,l, available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units:'4. Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments V 1 PKG. TREATMENT PLT. ❑ Method of Disposal p. Distance to nearest: Well Foundation Property Line Z LEACHING LINE b No. & Length of lines Total length/size FILTER BED f_] Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Ll 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, 1 shall no 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 appficankfpqust call f. alt wired inspections. Complete drawing on reverse side. _ter PY-q3_ Signed Title. .P,&-6►Nga2./06 A&Z1-D6«TDate: / - r FO EP TMENT USE ONLY ,P� Application Accepted by I Date , `o�" < 3 Area Pit or Grout Inspection by Date Final Inspection by Date� I 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 l . FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'N0. INFO . 6H13.24 IREV.1/n ei EH 14.20 ✓✓✓ ((JJ