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9— )JOAQUIN COUNTY PUBLIC 11EAI;' H I ENV111()NIdENTAL 1IEAL•l•II ES t 445 N SAN JOAQUIN, P110NE DIVISION��, P O BOX 2009, STUCKTON ACOA)49520 420 LL' _ 1 PERMIT EXP111ES 1 YEA1t FRO>]tj llATE1fISS � F (COlnplet� in Application is herebyTriplfca-:e;) fy g grade to San Joaquin County fore ' t! application 1a made 1n c l q permit to conatruct and/or-'nate 1 .Toaquln Count °� lance with Sao Joaquin Count Ordinance No. 4 y Public Health Services. 5 9 and 1 62 a c 6 nd the Rules and Regulations his 00 1 P of Snn Job Address 7 e" QQ OIC 1 — City £, j ' .Oh Lot Size/Acreage Q Owner'' Neme �7 rp11100' Address fy�Gfrr� 0�--- _ Phone 0 [Ile 9 s Conlraclor�SC�IG`/�r�CS�HGAddress .�BL r / _ 00 �/�^F� or t TYPE OF WELL/PUMP: NEW WELL5k5 � License No. J'y 4 Phone / 40 -�----�� PUMP fNS7ALLATION p WELL_ REPLACEMENT_fl `. DESTRUCTION L) Out of Service well Ll SYSTEM REPAIR J] DISTANCE 70 NEAREST: SEPTIC TANK fs OTHER p Monitoring well � SEWER LINES 6oi h �e/ ys 'r'� FOUNDATION i71 4r( SAr_ FLD. -� PROP. LINE AGRICULTURE WELL OTHER ,WELL TYPE OF IN USE �.., _PITS/SUMPS ----- WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial ❑ open Bottom a Manteca Dia, of SNefi Excavation ' f.1 Domeslic/Private 0 Gravel pace n Tracy T Dia. of Wall Casing VI Public Type of Casing__��VG Specifications C" * i't f) Other f-1 Delta Depth Of Grout Seal i! O:, it I I hriJarion o —Z— � � Type of Grout ♦ cY j GJ Approx. Depth I i Eastern Surface Seal Installed'by Repair Work Done LJ Type of Pump H.P, —��-•• tl'State Work Done Well Destruction ❑ Well Diametef Sealing Material a Depth 1� S Depth Filler Material A Depth y 3' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I f INo Septic s stem ;I p Y permitted if available within 200 leets Public sewer is installation will serve; Residence Commercial 1 —. Other Number of living units; Number of bedrooms Character of soil to a depth of 3 feelsjE i SEPTIC TANK ❑ Type/fNig " Water table depth ` PKG. TREATMENT CLT. Cl Capacity it No, Companrnents Distance to nearest; Well ,t Method of Disposal t Foundation Pr,party Line �x Q t: LEACHING LINE - E d �` Ll No, b Length of fines FILTER BED - l-1 Dlstanca to nearest: Total langih/size Wait Foundation� k# Property Line SEEPAGE PITS I I Depth Sire -- SUMPS ---- NUmber LI Distance to nearest: Well Foundation DISPOSAL PONDS ._ C] Profae►tY Lina h I hereby certify that I have prepared this application and that the work will Us done in accordance with ISan Joaquin county ordinances, state laws, and 0 i rules and regulations of the San Joaquin County i Home owner or licensed agent's signature ceniGes the following; "I cattily that in the per}ormanrca of the work for which this permit is issued, I shall not fl MOODY any Person in such manner as to become subject to workmen's in laws of California." Contractor's hiring or subcontracting signature certifies the following: "I cenify that in the performance of the work for which this permit is issuad, I shall employ persons subject to workman's Compensa— tion laws of California." The applicant must calk lot all required intpections. Complete drawing on reverse si(le, i £ Signed X!/ --- Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by F). -- Date ' `7i` Area Pit or Grout Inspection byFDate Final Inspection by Date F Additional Comments: Applicant -- Heturn all copies to: Sen Joaquin County l,ublic lleelth Services . Buvlronmentnl IIt•ulth !'ormit/Servicers - 445 N Sen Joaquin, p O 13,ix 2009, Stkn, CA-95201 FEE AMOUNT DUE AMOUNT CK INFO REMITTED RECEIVED BY I DATE PERM17'NO, o' • EH t324 I Rrv.din 6: FH 1/28 r .Y/e an