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�lrri,l L:a i I 0,NSAN �AQUIN COUNTY PUBLIC ENVIRONMENTAL HEALTH EALTHDIVISO P RVICES 445 N SAN JOAgUIN, PHONE (209)468-3420 0 BOX 2009, STOCKTON, CA 95201 PERg T EXPIRES 1 YEAR FROM D TE Application is here �COtD in Tr7` ISSUED ED aaequintmis made ° e Sm Joauin County for s permit to Pllcate JCounty Public He�HiB ry 'it, So. Joequln County mit to and/or install Services. O. 5 9 and the work herein described This Job Address 26501 1862 and the Rules and Banta Road — /� eaa t Regulations of San n Lzi,s p Tracy Owner's Name`�'fEro'Iftrrr-a.�--' -'^ Cr Lot Size CU �EYidy /Acre e 13.94 dCreS Address 83 Contractor V & W Dri l l i n Pno e�� 685�- TYPEOFWELL/PUMP AddressPD BOX 51 , Rio Vista, CA 05765 766 NEW WELL License No. PUMP INSTA WELL REPLACEMENT Cl Phone _ DISTANCE 7 TION DESTRUCTION L7 Out of 0 NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ Service Well �� SEWER LINES OTHER 0 Monitoring � FOUNDA710N ---_ DISPOSAL F!D. Well } 4 INTENDED USE �� AGRICULTURE WELL PROP. LINE —� TYPE OF WELL PROBLEM AREA OTHER WELL Industrul ,TYPE n� �_ P175/SUMPS CONSTRUCTION SPECIFICATIONS $: Domestic/private p° onk* ❑ !da"roca 1)7a ,___ _` �Gravel Pack Dia. of Wefl Excavation R i n h I'I Public 21 Tracy Type of Casing Dia. of Well Casing FI dine' n den, 9-� 40 P 9 2 Inch I i IT"Oabo^ Depth Of Grout Seal 10f Specifications—�_ Approx. Depth I I Eastern - f--� _ Type of Grout CP.I--- RepNf Work Done Type of Pump Surface Soul Installed by_V �t0 lte WNI Destruction &^""--s=l a-'nCi. ❑ Well Diameter H P l 1i,i70h Sealing material yal p State Worfk� Dq"a ---'-'—�� epth CPlnent/bento - e YOU Depth �S fry} '111er �— Meterisl i Depth YPE OF SEP71C WORK: NEW INSTALLA710N 1 AEPgIRrgDDITION Installation will serve: Residence DESTRUC710N I INo sepnc system Commercial evadable within 2 Permitted d public sower ra Number of living units: Other_ — 00 fest.) Number of bedrooms Character K wit to•depth of 3 feet SEPTIC TANK --� O Type/MfgWater table depth PKG. TREATMENT PLT. CICapaclty Na. Compartments Distance to nearest: Well Method of Disposal Foundation � Pro rt pe Y Line LEACHING LINE � No. & Length of lines - FILTER BED Q Distance to nearest: Well Total length/size Foundation SEEPAGE PITS Pr°pertY L'"° SUMPS I Depth —_Si:e DISPOSAL PONDS LI Distance to nearest: WeO �— Number 11 p Foundation � Property Lino I hereby certify that I nave prepared this at I Countyon and that the work will be done in accordance with San Joaquin county ordinances, stale laws, and rules end regulations of the San re, 1; County Home owner or licensed agent's signature cii ies the 1,1owing: "I certify that In the emplpy any person in such rtunner as to became mance of workmen's compensation laws of California.— Convector's hiring certifies the folPerson performance rn Me work for which this r Permit is isactin I B: ,. certify that in the Performance of the work for which this permit is issued, I shall em to shall not tion laws of California." The applicant must call for all r p y Persons sublet`to workman`s coin nature q required inspections. Complete drawing a^u' Signed X OLn Bon revere sada. X. Title: FOR DEPARTMENT USE ONLY Daf[e: Application ActroPtetl py 2 . Pit or Grout Inspection by Date ( / Area Da sinal Im Additional Comments: peetion by Date Applicant - Return all copies to: SanJoaquin County Public Health Services Env l roamental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stk., CA 95201 FEE AMOUNT DuE AMOUNT REMITTED INFO CK c� CASH RECEIVED By DATE PERMIT NO. ,a.24 3uEv.I,xal '3 ( 7 cl 0�-3 6 y `! 5 Page I3A u.ze 71 7