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SAN J04QUIN COUNTY PUBLIC HEALTH c VICES � V vVIRONXENTAIL HEALTH DIVISIf 445 SAN JOAQUIN, PHONE (209)468' -3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) t Application is hereby made to San Joaquin County for a permit to construct and/or harass the work herein described. This application is made in camplianee with San Joaquin County Ordinance No. 549 and 1862 snd the Rules and Regulations of San Joaquin County Public Health Services. /� p Job Address 2-00n RUG City Lo , t , Lot Sire/Acrea-ge `� 1 tact s�.. sa<< .7 Owner's n1 Owner's Name Address +s- r�-'� 5+ gyp one Contractor cL'%k- 1'_- Address 32 3 h FCo� %jrR. ca5�. L57 55`19 3Llt:enSe.�,Ne. Phone « • t TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT f"1 DESTRUCTION ❑ Out of Service well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ j OTHER ❑ Monitoring well DISTANCE TO NEAREST: SEPTIC TANK �� r _ 5Q I SEWER LiNES �S U _ OISPOSAL:FLD.�*�,r PROP. LINE �r FOUNDATiON �3O AGRICULTURE WELL 1.� OTHER WELL_2_5Q r PiTS/SUMPS —Z—SC.,r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ,. C1 Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation 's lC73,ameg Dia. of Well Casing r+IcL_ Ci Domestic/Private KGravol Pack 0 Tracy Type of Casing_'5e_k_o-JX '1() PVC Specifications i'I Public [1 Other 171 Delta Depth of Grout Seal _ .}� Aee.L.- Type of Grout 340 I I IrriOation 7Q Approx. Depth I f Eastern Surface Seui Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction Weil Diameter %. Sealing Material 4 Depth BtLlar..�e, �.r yQ. TO FeLf~ f Depth 0 re L Filler Material # Depth . S!��(�, 1c..•. �(5w-�= TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION l I DESTRUCTION I I (No'septic system permitted if public sewer is available within 200 feet.) installation will serve: Residence— Commercial T 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.❑ 4 Method of Disposal F I Distance to nearest: Well Foundation I Proprty Line I LEACHING LINE Cl No. & Length of lines Tonal length?i/size FILTER BED {l Distance to nearest: Well Foundation �, Property Line l� � SEEPAGE PITS 11 Depth Site Number SUMPS Lf Distance to nearest: Welt Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordan rules and regulations of the San Joaquin County Itie with San Joaquin county ordinance!, stere laws, and jl O 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 taws of California.".j Contractors hiring or sub-contracting signature certifies the following: 11 certify that in the performance of the work for which this permit is issued i I shall employ persona subject to workman's compensa- tion laws of California." The appfic u I cif requiry inspections. Complete drawing on reverse side. Sisnad K Title: CK4Date: S Z S Z FOR DEPARTMENT USE ONLY Applicstlon Accepted by Oate Area Pit or Grout Inspection b pe V Data final inspection by FDate t. Additional Comments.- Applicant ommentf:Applicant - Return all coples to: San Joaquin County Public health Selviceq,:J Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA �95201 FEE AMOUNT Df1E AMOUNT REMITTED CK RECEIVED BY INFO CASH DATE PERMIT'NO. . EH 13.24 IREv.it"St EM 11.26 P j i� h