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SAN CQUIN COUNTY PUBLIC HEALTHVICES �,+J (�toPvpx leu.-ITEgs IRONMENTAL HEALTH DIVISI QQ 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009 STOCKTON, CA 95201 PERMIT E%PIRES 1 YEAR FROM DATE ISSIIID (Complete in Triplicate) Application in hereby made to San 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. work ♦ ( +'u sVIell elk JobAddcess 39-15N-agy pr City 5t4;Gk*41 Lot Size/Acreage OWVIL� of proptrfY WwP- j Con dwu an: Owner's Name Address RDIX✓'f- StillrJw Addle'"' �07q E. M''t`✓r htyafc{7rY' Phone -,I h II Contractor TU✓✓K✓ Fa�a"C�l� Address*Z41 n�er Ra�ho License No. Phone TYPE OF WELL/PUMP: NEW WELL J WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER .� ! u� _1 Well ❑ DISTANCE TO NEAREST: SEPTIC TANK U."� 1`7' SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 2L4Lfr'k'� AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS LI Industrial ❑ Open Bottom ❑ Manteca Die. of Well Excavation Z Dia. of Well Casing �K' F Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing iJ Specifications N r Il Public I.1 Other n Delta Depth of Grout Seal Type of Grout Irrigation _Approx. Depth I I Eastern Surface Seal Installed by 4' Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i epth Depth IS/ pier erial i pth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRDDITIh(� ON 111 DE RUCTION I I INo septic system permitted it public sawer is �. \\�\\— available within 200 feet.) Installation will serve: Residence_ ComrrEercal_ that \ Number of living units: _ Number of Dedrooms Character of and to a depth of 3 feet: Water table depth P� SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ � Method of Disposal Distance to nearest. Well Fo datioju Property Line y1` LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest W Foundati i Property Line SEEPAGE PITS 11 Depth Size 1 Number SUMPS LI Distance to nearett: Well Foun n Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in atrmance rdance with San Joaquin county ordinances, state 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 pe of the work for which this permit is issued. I shall not employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is iiilued, I shall employ persona subject to workman's compensa- tion laws of California." The apPlican,t��pp��Et�� call for all required inspgctions. Complete drawing on r./v se side. Signed X � //i/iL�— Date: j r FOR DEPARTMENT USE ONLY Application Accepted by JD'dI. Data Pit or Grout Inspection by Data Final Inspection by Date Additional Comments: J Applicant - Re(grin all copies to: San Joaquin ounty Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DAT PERMIT NO. INFO << / (]'SCCASSH ', / ..}}�� L^' /A� 2/�7 • EH Ii-I4(REV.1r x 5) . r/6 .00 1✓ 73' A#- ( ( L VO/C-7J EH 14aa