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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) pirllcation is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This pplication is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San oaquln County Public Health Services. l C'1 _ >b Address �m /� � [Aly .7 Ew Loo Rd City City de div Lot Size/Acreage wntvi Nome 6&44 95b Address 2f 5C/ C(/Ikie4 t"C*1W 4C/ Phone ontracter pIl tSel�.. Ad r�� F' /� �V K/ License No. ' 2S'.?2 :� Phone YPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well ❑ (STANCE 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 I Industrial ❑ Open Bottom ❑ Manteca Ore. o1 Well Excavation Dia. of Well Casing I Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications I Public 171 Other fl Delta Depth of Grout Seal Type of Grout I lnigatlon _Approx. Depth I I Eastern Surface Seal Installed by spair Work Done ❑ Type of Pump H.P. State Work Done _ leg Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth YPE OF SEPTIC WORK: NEW INSTALLATION I I IZIIEPAIRDDITION I I DESTRUCTION I I INo septic system permitted if public sewer is // available within 200 feet.) Installation will serve: Residence ✓ COmmercisf_ Other Number of Going units: _/— Number of bedrooms:— Character of sell to a depth of 3 feet: Water table depth EPTIC TANK ❑ Type/Mfg Capacity No. Compartments KG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line EACHfNG LINE ❑ No. 8 Length o1 lines Total length/size ILTER BED ❑ Distance to nearest: Well At.* Foundation 1Q/' Property Lim EEPAGE PITS 11 Depth +-S Size 3 f+�� AT '/INuumber�C UMPS LI Distance to merest: Well /Dpi- Foundation /Qli— Property Line ISPOSAL PONDS ❑ hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and des and regulations of the San Joaquin County aM owner a 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 mploy any person in such manner as to become subject to wo(kman's compensation laws of California." Contractor's hiring or subcontracting signature ertffies 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 on laws of California." he applicant mus I for all required inspections. Complete drawing on reverse side, iprrod x �(/.t�✓✓&ffrlj Title: Data: /�//1 FO DEPARTMENT USE ONLY pplication Accepted by " L)9� (�L, Date Area L Grout Inspection by Datjy[ �Final Impaction by Date ddhional 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 NFO AMOUNT DUE AMOUNT REMITTED RECEIVED By DATE PERMIT'NO. / %IaEV.rrxs Ob — 37 �/