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SAN JOAQUIN COUNTY PUBLIC HBALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) .nation is hereby made to Sm Joaquin County for a permit to construct and/or install the vork herein described. This 11eation is made in compliance vlth Sm Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San { quip County Public Health Services. dress yl /� r{ nf11o�FS30 ..�P "t.'Q1F`lra ted 14e City /)4j Lot Size/Acreage rrt Name &3043r—" /_ f L?Ai.f Address _ L f 10 C(Ak4P.1e -Jcr}9Cj' 4W Phone ,4t1 Sr Eo n AfBtta � Addresa:j!S e .td i License Phone IE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER O Monitoring Well O 1v4CE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. - PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS II ENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - rLsuw ❑Open Bortom ❑ Manteca Dia. of Well Excavation Dia. of Well Casug Domestic/Prorate ❑ Gravel Pack O Tracy Type of Casing_ Specifications P,"x Ll Other fl Delta Depth of Grout Seal Type of Grout n ttion _Approx. Depth 1 I Eastern Surface Seal Installed by - m r Work Done U Type of Pump M.P. State Work Done_ a Destnrction O Well Diameter Sealing Material c Depth Depth Filler Material a Depth PLw3F SEPTIC WORK: NEIN INSTALLATION 1 I EPAIFIlrf DDITION I I DESTRUCTION 1 1 Mo septic system permitted it public sewer is available within 200 feat.) _ ar'-Yetion will serve: Remittance✓ Commercial_ Other 1t ber of living units:----F-- Number-of bedrooms :3 _ :Zsct r of seal to a depth of 3 feet: Water table depth PTIC TANK. O Type/Mfg Capacity No. Compartments G TIEATMENT PLT.O - Method of Disposal Distance to nearest: Well Foundation Property Line A- IING LINE ❑ No. b Length of lines Total length/size .1 1 BED O Distance to nearest: Well AVOY' Foundation fa' Property 1- 4'1- EPAGE PITS 11 Depth '1�4 Sae 36 Je al- Number C2 ` 11 S - LI Distance to nearest: Well 140+- Foundation Property Litre s2 , - � S1vSAL PONDS O weby Certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and Is ad regulations of the Sm Joaquin County ' v owner ar ficermad agent's signatwa owffiiss the following: "I certify that in the performance of the work for which this permit is issued, 1 shag not ipwy any person in such manner ss to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature Oibss the following:'I certify that in the performance of the work for which this permit is issued,1 shelf employ persons subject to workman's compensa. *.sous of California.- * tpicam for aN required ktapections. Complete drawing on reverse side. gnsd X (../ihfA/t`7'� Title: /ri'LGtiy�- Date: I/J (� 57Z F(o DEPARTMENT USE ONLY *p tion Accepted by-:72— �it N Date Y'/�_�L 7 Area P6 Grant Inspection by Dat Final Inspection by Date k_onal 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE M . o� crc 4- J