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SAN JOAQUIN COUNTY PUBLIC HEALTH SERGICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 4 ' 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 work herein described. This application to made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. L Job Address/ '/ e /�K �Q/� ----- CityS/VC4_ 464Aot Size/Acreage Owner's Name, 1s�A�d 1aYd Address O/� Phone V-1!7 �1 Contract s t-`++ Address ?. tO L�-DJC _ _ License No. 73 Phone A& 1Z TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 1-1 DESTRUCTION L-i Out of Service Well n PUMP INSTALLATION�*-' SYSTEM REPAIR Ll OTHER ❑ Monitoring Well p DISTANCE TO NEAREST: SEPTIC TANK ��+_ SEWER LINES DISPOSAL FLO. _0 PROP. LINE -/arf FOUNDATION AGRICULTURE WELL � , OTHER WELL PITS/SUMPS . S40 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICA—T-IIO�jS— [�l�Industrial ❑0��OOpen Bottom ❑ Manteca Dia. of Well Excavation [�f•• Dia. of Wall Casing Domestic/Private VOGravel Park L Tracy Type of Casing_ _ c f Specifications r+, 1'1 Public 1-1 Other P Delta Depth of Grout Seal _�`s,� 7J1 Ty of Grout I I Irrigation )�_Io/Approx. Depth stern Surfa a Seul Installed by Repair Work Done U Type of Pump t H.P. /XZ_ State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material ii Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sower is available within 200 feet.) Installation will serve: Residence __ ommerc'al Other ` d.� Number of living units: Number of dmcims Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg capacity— No. Compartmanti PKG. TREATMENT PLT. ❑ ' Method of Disposal_ Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. 8 Length of lines Total length/size FILTER BED Cl Distance to nearest: ell undation Property Line SEEPAGE PITS 11 Depth Size _ Number SUMPS _ LI Distance to near t: Well Foundation Property Line DI OSAL PONDS ❑ a 1 hdreby cerfify 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 license ' signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any porton ' such mann as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the foil ing: ' certify t t in the performance of ork for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of ifornia." The applica must II f quired s /� et ing on ve side. Signed X r Title: y Date: FOR DEPARTMENT USE ONLY Jk Application Accepted by Date /0 _ Area �Z/ ` 4 Pito Gr1ou Inspection by (� Date � Al—f�Final Inspection by / 1 G1 Date Additional Comments: i 44, c� <t7110/�'LS��1 l �� _jam //`/ 19 /0 4e-_ 'D Applicant - Return all copies to: San Joaquin County Public Health Services G"/4,`-`'`-"`�',�p / yy Environmental Health Permit/Services 1I 445 N San Joaquin, P O Box 2009, Stkn, CA 952011 ,}(4,AJ�/4i.-)IV- 'if 47-1 FEECK INFO AMOUNT DUE AMOUNT REMfTTED CASH RECEIVED BY DATE PERMIT'NO. EH 13 t/1REV,iihsr li, N 13y p� �; iy '` {�c1 , -2e—�� =� EH 14 is