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eupr IC"'i"_CIN SAN QQUIN COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES Z YEAR FROM DATE ISSUED I I (Complete in Triplicate) PN ]2j 0 l� Application is hereby made to $an Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin Coun Publ Health Services. Job Address O r i h S �0 G k f(7 5 1City ]�pG r`�On Lot Si xe/Acreage / f IV-27 r1` kk ��` t7 ( NA 5 y,,(I,e , /57, Phone [ [ f Owner's Name l�� Ulg�l�ddress J. _ �e/e/. S 1.er 'f p Esc s � • r lean (e �3 �!!, 5 Phon Contractor [ � �nV. Fl` Qrc Address License No. TYPE OF WELL/PUMP: 1k:: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ i.IPUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Oir -I`IO -f 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 Cl Industnel ,L:I❑ Open Bottom D Manteca Dia. of Weil Excavation 16 ' _ Dia. of Well Casing [.] Domestic/Private fu❑ Gravel Pack C7 Tracy Type of Casing- out c 4e� pNG Specifications I'! Public r - of Grow `��C Prh rK� tYo r fl Delta Depth of Grout Seal .a►afax 8 Type tir{ I I Irrigation +`"•�IIII!. �Approx. Depth 11 Eastern Surface Seal Installed by- a✓:I1,� - Repair Work Done ❑ .Type of Pump 5"i7 frsr it H.P. State Work Done Well Destruction ❑ Well Diameter � Sealing Material & Depth p n'tu 4 c l� s y Depth Filler Material & Depth 5 ti III,el p TYPE OF SEPTIC WORK'.: NEW INSTALLATION k I REPAIR/ADDITION E I DESTRUCTION I 1 (No septic system permitted if public sewer is available within 2170 feet.) Installation will serve: Residence _ Commercial Other Number of living units:lr Number of bedrooms • Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK IIS Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.I[] Method of Disposal Distance to nearest: Weil Foundation Property Line LEACHING LINE Cl No. & Length of tines Total length/size w FILTER BED C7 Distance to nearest: Weil Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ILl Distance to nearest: Well Foundation Property Lina DISPOSAL PONDS 0 I hereby certify that I have prepared this application and that The work will be done in accordance with San Joaquin county ordinances, slate laws, and rules and regulations of the San 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-contracting signature cenifies 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- tion taws of California." The applicant must tali for all x4red inspections. Complete drawing on reversepide.Signed ' Title: „5_'yT� petr i 0 ri 15 ate: Lgllo�, F R D PARJM�EW USE ONLY Application Accepted by Date Area Pit or Grout Inspection bV Data FFirud Inspection by Date Additional Comments: i r Applicant - Return all copies to: 6. Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Sox 2009, Stkn, CA 95201 FEECKINFO AMOUNT DUE AMOUNT REMITTED RE CASH EIVED BY DATE PERMIT'NO. I EM 17-24 IAEV.i 5) EH 14•I0 1,;g i .O0 .V 0 • 5 a J �� 5 �f