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SAN RUIN COUNTY PUBLIC HEALTH *VICE ENVIRONMENTAL HEALTH DIVISION YPTIVTO445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 32 O, STOCKTON, CA 95201-038�U.14 15 1995 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) ENVIRONMENTAL HEALTH PERMIT/ n�Ef��1�� Application is hereby made to San Joaquin County for a permit to construct and/or install the work here ed. 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. nn � Job Address C0.v-11 1�' �2�. City Man��e Lot Size/Acreage �6 Clr F{G+-- CS ../. I (6/s) Owner's N� 6� O�,r� ( .Uf Address p solar L1S*,iiI lGV phone 9520 �z�) ContractorYYL I Address Z3 1 Lu0. 5-C License No.SIZZ68 Phone.PLZ TYPE OF WELL/PUMP: NEW WELL1W WELL REPLACEMENT 11 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ,�O1�r.T4HER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK L'— SEWER LINES >/00 1 DISPOSAL FLO. AJA PROP. LINE FOUNDATION —L-1-L— AGRICULTURE WELL -AZA— OTHER WELL_ PITS/SUMPS /a� I Bnn INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 11 L) Industrial ❑ Open Bottom .0 Manteca Dia. of Well Excavati,o�n / - Dia. of Well Casing - nclI 9 Domestic/Private ❑ Gravel Pack 11 Tracy Type of Casing r V C Specifications :5_- A '40 I'I Public Vol her n Delta Depth of Grout Seal I I �tG'I' Type of Grout NEat CeAMA-k I I Irrigation 35�Approx. Depth I I Eastern Surface Seal Installed bV—T r tNtl�F��Of Li'�i OVI Repair Work Done ❑ Type of Pump H.P. State Work Done_ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 Is Installation will' e: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of Water table depth SEPTIC TANK ❑ Type/Mfg _ apacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Wel Foundation Property Line LEACHING LINE ❑ No. & Length o as Total length/size FILTER BED ❑ Distance earest: Well Foundation Property Lina SEEPAGE PITS 1 1 pth Size Number SUMPS 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, 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 must call for all r wired inspections. Complete drawing on reverse side. Signed XDA MM _P 6�- Title: 'PCO. cea ate: 4Q6.//411/7,5__ F R D P TMENT USE ONLY !/^ Application Accepted by L Date Area q"u� Pit or Grout Inspection by Date QS final Inspection by + Data Z ` 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, Stirs, CA 95201 0 INFO FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY 1" DATE PERMIT NO. • EH 1134IREV.1/n[rl 8 ,� �• nrt �I�