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SAN JC IN COUNTY PUBLIC HEALTH SESCES VIRONMENTAL HEALTH DIVISIO 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) Application is hereby made to Sm 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 County Public Health Services. Job Address Z99,� ti J7, City 5_106 .ID� Lot Size/Acreage y ACRLSS Owner's Name 54nrk A- J;I!5 PAuffc. &MIVICAddress $ 5• FIbUEC`j} LA CA `TOO"? Phone 13 986-F9s'� Contractor 9_L6T4✓^ -KPLd&r(NdAddress ZS15 F. MYOU .5W*)z'^License No. $/Z2(,$ Phone r TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Nell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ THERr P, 'Monitoring Well X DISTANCE TO NEAREST: SEPTIC TANKUQ- SEWER LINES DISPOSAL FLO. �� ^RcOYP. LIN 6 FOUNDATION — AGRICULTURE WELL OTHER WELL LIS PITS/SUMPS = • j�f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C L, ❑ �'it'��-; Industnal Open Bottom ❑ Manteca Dia. of Well Excavation A' Dia. of Well Casing y [I Domestic/Private ❑ Gravel Pack ❑ ScN yo to Tracy Type of Casing V Specifications •02 Sia I'I Public I-.] Other fl Delta Depth of Grout Seal ZJr x.30 Typeof Grout Cc&-t 6-.J 17- 1 1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by -�rG/Xy"� ��• Repair Work Done ❑ Type of Pump N.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer a available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: _ Number of bedrooms Character of and to a depth of 3 feet: Water table depth _ SEPTIC TANK ❑ Type/Mfg Capacity PA 11.-�!^ents -� PKG. TREATMENT PLT. ❑ IR /•G [021+hb •ltsposal Distance to nearest: Well Foundation A P Q n 5 %11,11 LEACHING LINE ❑ No. & Length of lines Tog MMrp FILTER BED ❑ Distance to nearest: Well Foundation �t�t1erpF{9f(gf.jgd',I;I•'1'�' ''" FNVIRONMENIALrikg:Tl-lWiVi14iON SEEPAGE PITS 11 Depth Size Number SUMPS - LI Distance to-nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state lawn,, 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 of sub-contracting signature__ certifies the following: "I certify that in the performance of the work for which this permit is issued, Ishall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all rnpf6d inspections. Com to drawing on reverse side. Signed X Title: �iQdJeGJ IfYMOii.EZL06rtSJ tato: 3_-10_e)`( t FOR,DEPARTMENT USE ONLY \ •/-,;�f Application Accepted by -U Date Area Pit or Grout Inspection by f Date f1 Final Inspection by` 1' uJ \Date Additional Commissars: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE I AMOUNT DUE AMOUNT REMITTED CKT RECEIVED BY PEflM1 'NO. INFO ryt CASH `gyp 'DATE I ./I1 . EH 13241 REV.1r45) - ` t �7n�// - •7J� a ' IJ EH 14.26 U