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arx , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ^ j ENVIRONMENTAL -REALTH DIVISION J 445'N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 ?C"rtn P QpD, t�� PERMIT E%PIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby sable to San Joaquin County for a permit to construct and/or-install the vork herein described. This application is made in compliance vith Bao Joaquin County Ordinance No. 549 and 1662 and tJfe�Aylee.amd Regulations of San Joaquin County Public Health Services. ��,/ /Y�✓� 4 /OS' OP, _ 12- Job 2- Job Address '�7 1. {.� / fl City �1 /`=A--K= Lot Sire/Acreage �'7 �F!_ Owner Name Address �// /� �T s6 a,4 J r/+-- Phone a. Contrauoy��L. �;w c Address a "y �..T.��/aµ P License No.��Qyd Pnon TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION Ll Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER O 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 0 Industrial ❑ Open Bonom O Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack,.- --- 0-Tracy ....-Type of Casing_ Specifications _ I'1 Public ❑ Other fl Delta Depth of Grout Seal Type of Grout <1,,vation _Approx. 00� �I,Eastern Surface Seal Installed by es Repair Work Done AType of Pump..79b_6`ae H.P. `FCS State Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material.4 Depth i TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ij DESTRUCTION 1 I INo septic system permitted it public sewer is available within 200 feat.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ .Number of bedrooms Character of soil to a depth of 3 feet: \ water table depth SEPTIC TANK ❑ Type/Mfg "/Ca Paci t Y --No. Compartments PKG. TREATMENT PLT. ❑ it t. '1 Method of Disposer Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No.4 Length of lines Total length/size FILTER BED ❑ Distance to nearest Well Foundation Property Lina SEEPAGE PITS 11 Depth Size _ Number SUMPS LI Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this apolication and that the work will be done in accordance with SanJoaquin county ordinances, state laws, and rules and regulations of the San Joaquin County ` - C 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, 1 shell not employ any person In such manner as to become subject to workman's compensatiofi 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 workmen's mpensa. tion laws of California." it The sat mus as for all req `asps oro. Complete drawing on side. Signed Title: —T �� - Date: OR DEPARTMENT USE ONLY 1 Appkation Accepted by A6. L r 1T,i Date Area i Ph or Grout Inspection by Date Final Inspection by Date 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, Stkn, CA 95201 FEEINFO AMOUNT DUE AMOUNT REMITTED CASH pRECEIVED BY DATE PERMIT NO. - EK 3-H EN H.mtaEV. xer