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SAN JOArTT N COUNTY PUBLIC HEALTH SERV'^ES � D RONMENTAL HEALTH DIVISION k: 445 N 5�v JQA�UIN, PRONE (209)468- 0 P O BOX 2009, STOCKTON, CA 95201 - 't�ry Jl/1 ul'--4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby madelto San Joaquin County for a permit to construct and/or install the Work herein described. This application is made in com;211ance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San i Joaquin County Public Hfalth Services. I Job Address ' �Lmtr` `� 'r4 City LOJ i Lot Size/Acreage {I�' �c,Ylc�pa"r)Owner's Name "' C-f ry�� Address �r� �a5 Phone :1A N11�rhel! �r��I6n Fzancl�c, cu- ori est O�re Contractor_ 9 Addressl� �2� Ll[ License No. _72417 Phone TYPE OF WELL/PUMP: ' NEW WELL WELL REPLACEMENT Cl DESTRUCTION Cl Out of Service Well Cl PUMP'INSTALLATION O, SYSTEM REPAIR ❑ OTHER ❑ , Monitoring well C7 DISTANCE TO NEAREST: SEPTIC TANK 2-100 SEWER LINES U-410or DISPOSAL FLO.. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL , PITS/SUMPS f , INTENDED USE TYPE'OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS /1 C7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Wefl Casing 'Z i 171 Domestic/Private ❑ Gravel Pack C] Tracy Type of CasingsG�? 9r7 r�C 1'1 Public MOA 4W 1-1 Oihei Cl Delta - Specifications r —� Type �/,��y iii Depth o! Grout Seal 5 yp of Grout rid I I Irrigation -1_{L Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L3 t Type of Pump H.P. State Work Done _ ^, Well Destruction ❑ Wet] Diameter Sealing Material a Depth V v [lI NO)l t*l Depth 11 Filler Material 6 Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I 1 REPAIR/ADDITION I l DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial— Other 1 Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: .KWater table depth SEPTIC TANK ❑ 'Type/Mfg Capacity. No. Compartments PKG. TREATMENT PLT. ❑ �I Method of Disposal I Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. &,Length of lines Total length/size FILTER BED C7 Distance to nearest: Wail Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared',Ihis application and that the work wiil be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin County I 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 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 certifies the following: "I certify that in the performance of the work for which this permit is issued, l shall employ tion taws of California." parsons subject to workman's compensa- j The applicant II for aj required ins p , tin Complete drawing on rev rse side. Signed XI'I r / Title: ti Date: �d ' FOR DEPARTMENT USE ONLY ✓ �('`� Application Accepted by Date Area !L4l1 e Pit or Grout inspection my Date Final Inspection by Date Additional Comments: ti Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services I 445 N San Joaquin, P 0 Box 2009, Stkn, CA 952011FEE L1 INFO AMOUNT DUE AMOUNTT REMITTED CK JV H RECEIVER t3Y DATE PERMIT NO. 2b s fAEV.sir s, III I�,