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` SAN J(QUIN COUNTY PUBLIC HEALTH SICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-34201 P O BOX 2009, STOCKTON, CA 95.201 I 1�1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED .I "-(Complete in Triplicate) " Application is hereby made to San Joaquin County for a permit to construct and/or install the.,work herein described. This application ie made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. `r Job Address 4S� rS- N. Pe H1+�� •AV City STbtle-To'`d Lot Si� /Acreage ` coo +� $a I%T'rC N e2t ��RM g L 8 rt V ST (.3c .57 _ Owner's Name �P(� fn -3 4TH Address �er,4yc�}L t7 gp Zoe Phone �Z �5 II yz t�t�rijzy DRIv� -7 -Address cstt� � Cartlractor �i�E {� 1 Ll.l 1►�61—Address At tJ g rrLicense Noy 80 6S_ Phone �aO' y Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 5 DESTRUCTION LI Out of Service Well ❑ PUMP INSTALLATION 9 SYSTEM R�PAIR u OTHER ❑ Monitoring Well K ` DISTANCE TO NEAREST: SEPTIC TANK 570� SEWER LINESs� DISPOSAL FLO. W16' PROP. LINE T 3S FOUNDATION ) rap _ AGRICULTURE WELL Yh— OTHER WELL PITS/SUMPS 7SQ� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z rr 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation JI.Dia. of Well Casing Ci Domestic/Private E'rGravel Pack7 ❑ Tracy Type of Casing_ py C_ Specifications SS" `i0 I'i Public n Oper " n Delta Depth of Grout Seal ZO ;} Type of Grout PDX-rLAP40 Cly 01. I I Irrigation 3S_' Approx. Depth I I Eastern Surface Soul Installed by D L.Lf Repair Work Done U Type of Pump r4OP4 f H.P. State Work Done _t Well Destruction ❑ Well Diameter Sealing Material i Depth Depth it Filler Material i Depth I. TYPE OF SEPTIC WORK. NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted ii public sewer is available within 200 leet.l f w I V installation will serve. Residence Commercial_.. Other wf Number of living units: Number of bedrooms I Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg Capacity , No. Compartments IN C3l Method o}'Disposal PKG. TREATMENT PLT. w Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size �Il FILTER BED Cl Distance to nearest: Wall Foundation Property Line'T SEEPAGE PITS 11 Depth Size Number - SUMPS Ll 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 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 certifies 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 applica ust all for 11 required inspections. Complete drawing on reverse side. 4- !. Signed X Title: Date: ez R DEP RTMENT USE ONLY Date .� Area 3 3 Application Accepted by Pit or Grout Inspection by Date 2- incl Inspection by Bate i� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services ?� Environmental Health Permit/Services -h ;, i rl 445 N San Joaquin, P 0 Boit 2009, Stkn, CA 95201 INFO AMOUNT otlE AMOUNT REMITTED CASH K 9 RECEIVED BY DATE PERMIT NO. r i EH 13.74 tFIEV.1/e5) 07, 00 2 G� fo-/.; 2— !�'�