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i5crJ,Q SAN ,. COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 riJ heP4.1 �� P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application 1s hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in coupllance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Health Services. 1 Job Address Ci t 91 ze/Acreage - 77 / Owner's Name - r � Address �� Phone -7v a" Contractor l �T�1 '1/1,�9j 'v Address /2License No. 1_(L2U L-"`rhone TYPE OF WELL/PUMP: NEW WELL " WELL REPLACEMENT DESTRUCTION ❑ Out of Service Well PUMP INSTALLATIO SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well C]r DISTANCE TO NEAREST: SEPTIC TANK g SEWER LINES Z 4-,y_. DISPOSAL FLO. — PROP. LINE FOUNDATION �_ AGRICULTURE WELL OTHER WELL` PITS/SUMPS /69 -- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r 111Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well Casin �� L Domestic/Private �7q�Gravel Pack C1 Tracy Type of Casing _ Specifications 9"1 Public I.1 Other fl Delta Depth of Grout Seal _ ,f'Type Grou O (, 1 Irrigation ��✓✓ _Approx. Depth ,III E'asterLgr Surf a Seal Installed by \ ` Repair Work Done Type of Pump_ >lj.`L�L %14.P. y State Work Done Well Destruction Well Diameter Sealing Material a Depth Depth 6y b Filler Material a Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) \ Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms ` Character of and to a depth of 3 feet: 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. & 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 Line DISPOSAL PONDS ❑ 1 hereby comity 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 Sah 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-contrapting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa tion laws of California." The applicant must all for all required inspections. Complete drawing on raver B ide. Y� J 9 / Signed �� ~---"Phis: C- a Date: 1,17111 IAZ,��aF R D ART ENT USE ONLY ' F � -� Application Accepts byDate ' . I Area Pit or Grout Inspection by j DateL�?Final Inspection by t^' Date 7-Z- 9 L. ` Additional Comments: 7&frMIJAq Applicant - Return all copies t San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 ` FEEAMOUNT DUE AMOUNT REMITTED CK 11 ELEIVED By DATE PERMIT'NO. _ NFO_ /CASH EM 13241aEV.ve51 EM 4211