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SAN J QUIN COUNTY PUBLIC HEALTH S VICES '-10VIRONMENTAL HEALTH DIVISION' 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED FILE C O P Y (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. It,/ �Qw/� �Jr Job Address wi 2 X City v/ Lot Size/Acreage 7_1 Owners Name � �L/L Address rSA Al Phone bfz Z-,e Contractor/CC/77r C-f�D�s Address �DI,71�! s /� License No.-3773rr Phone wY� TYPE OF WELL/PUMP: NEW WELL Pie WELL REPLACEMENT n DESTRUCTION t of Service Well Ll PUMP INSTALLATION �C SYSTEM REPAIR ❑ OTHER ❑ • Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.,LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casim ,SkDomestic/Private ,Gravel Pack ❑ Tracy Type of Ca e Specifications I'1 Pudic _7 sn OtOt r®y�� / fl Delta Depth of Gr t'Seal ...�y,,T•ype of Grout C I I Irrigation 7��A-pr Dep th I I Eastern Surface Seal Insta '" "� Repair Work Done jiae Type of Pump -Ta'HAf H.P. S State Work Done a Well Destruction >�.- Well Diameter jr= — Sealing Material a Depth Depth Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system ted it public sewer is ./!7 available within 2084") Installation will serve: Residence_ Commercial_ Other Number of kving units: _ Number of bedrooms Gharalver_of wil to a.depth of 3 feat: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal- Distance to nearest: Well Foundation Property Line LEACHING LINE C1 No. 6 Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number ) SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS O 1 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." Contractors 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 musJ call for all required inspections. Complete drawing on reverse side. /�(��y. "j-La-4l Signed x Title: 11L✓AS�I.. Date: O ARTMENT USE ONLY a Application Accepted by/ Date - '7-I_ 1 L Area � Pito Grout spsoan TSy, Date/ Final inspection by D t"" a �Z Additional Commantrl:/ ,Applicant - Reto all copies to: SaVJoaquin County Public Health Services AQ Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PEflM17'NO. u.� A 9Z - '7/ EH t}24(REV.irxm) Pwl af,S•,C7 t7 !L fC`7 ��Zt7 -7-P EH 1411 /°� fodrO