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SAN JOAQUIN COUNTY PUBLIC HEALTH SLAVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN , PHONE ( 209 ) 46811113420 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 vork herein described . This application is made in compliance vlth San Joaquin County Ordinance No . 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Servic s . 1 Kln SIn-nd �te'stl- - Job Address 5 o \A40i A 1't •f Y1'1Ja /1 CK3 GL Ciry Dl, Lot Size/Acreage . / �/ ikoo �au-relf ny)y1)h ,B/ vd •� Ste. 2115)Owner's Name VAP . i .re Prf) pflr ��eS Address 140 1,k11I/ AIO(�/ C4 q) AnlL Phone 91917,63 _d /�yt z8a5 E vnyrtlte 5t ao9 Contractor Cja. LL" IOY Wress hJt^wk4M a eill /JreZOSLicense No . l0ZaJO Phone TYPE OF WELL / PUMP : NEW WELL WELL REPLACEMENT R DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR [I OTHER C3 Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SD SEWER LINES > 50 IT DISPOSAL FLD . w 1 PROP . LINE ZD r FOUNDATION > 5n r AGRICULTURE WELL Zr�D 'OTHER WELL ,�' D PITS / SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation R Dia. of Well Casing EXD msatic/ Privateq ❑ Gr Val Pack ❑ Tracy Type of Casing pV c Specifications fVD/�/41 'TOR �.�10ONTO ��— I '1 'P17Fi '�N Other W i(,J,. If Delta Depth of Grout Seal 0 4,0 Type of Grout I I Irrigation LLApprox. Depth 1 I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H . P . State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Tiller Material i Depth TYPE OF SEPTIC WORK : NEW INSTALLATION I I REPAIR /ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is v^\ available within 200 feetJ Installation will serve : Residence _ Commercial _ Other Number of living units: _ Number of bedrooms Character of wil to a depth of 3 fast: 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 ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Lina 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 applica us call fot, afl required inspections. Complete drawing on reverse side. l Signed r"�\ , � r- � Title : ' ,"" �'' � 1� Date: �I �'�S �f —S FOR DEPARTMENT USE ONLY Application Accepted by � Date ` —�� Area Pit or Grout Inspection by Date 1'� Date C /7 y ? Final Inspection by u � Date Additional Comments: A Applicant - Return all copies to : San Joaquin County Public Health Services r Environmental Health Permit / Services 445 N San Joaquin , P O Box 2009 , Stkn , CA 9520FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PtAM17 NO. . EH 14-22 4 lkil11R1'V. tieplmEH 11gy Fy �� - L ?3 !319;9