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[ S SAN JUIN COUNTY PUBLIC HEALTH 310ICES ENVIRONMENTAL HEALTH DIVISION ' 445 N STAN JOAQUIN, PHONE (209)468-3420 P O 'BOX 2009, STOCKTON, CA 95201 : i k PERMIT :EXPIRES I YEAR FROM DATE ISSUED € (Complete in Triplicate) G, EI ' Application Is hereby made to San Joaquin County for a permit to construct and/or install the1vork herein described. This application is made In compliance with San Joaquin County Ordinance No. $49 and 1862 and-the Rules and Regulations of San Joaquin County Public Health Services. fii Hi►�S Avg IIS Job Address L{ rsr N• 'Ft City 1 bCreToH Lot Size/Acreage '?jq 00 $o*-r"tc H fzt'L t�E'S I cs RN 82-8 tl TH ST kI (3 a 3 3 s OetAveZ co SO Lo L • _ Phone C 1 ' �J Owner's Name Q2uP� Tic- T� Address �-. yz 6eR•R-{ flRtvrs C-- 5-7 Contractor C,�-E Q.L L.L.1 rd Address R ALH ECO r'.rLicense No y 80(OS Phone I;gn' T4 L4 Z TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT r, DESTRUCTION t=I out of Service well ❑ PUMP INSTALLATION n 9 SYSTEM R�PAIR a OTHER C Monitoring Well 19 DISTANCE TO NEAREST: SEPTIC TANK SO SEWER LINES SO DISPOSAL FLD. N Ilk PROP. LINE IDS-3S i FOUNDATION 1S 1° AGRICULTURE WELL J_A OTHER WELL NL&S1L PITS/SUMPS �s� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS j rr ED Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation :L Dia. of Well Casing j Ci Domestic/Private ErGravel Pack C1 Tracy Type of Casing_ Psis_ 15pecilicatians_ 5544 �P t jf I'I Public f-1 Oer n Delta Depth of Grout Seal Z Q i Type of Grout pO�Tc hJ•!D CQ I I Irrigation 3,�C Approx. Depth I I Eastern Surface Seal Installed by1,LL•f l+f 2. Repair Work Done U Type of Pump wloriy H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Depth ' Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADOITION I I DESTRUCTION l 1 iNo septic system permitted it public sower is Cl available within 200 feel.l Installation wiil serve: Residence_ Commercial_„ Other Number of living units: Number of bedrooms ! �/ Character of anal to a depth of 3 toot: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method lof Disposal Distance to nearest: 'y Well Foundation Property Line �� w LEACHING LINE Cl No. & Length of lines $ Total length/size— FILTER ength/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line," "" SEEPAGE PITS 11 depth Sire Number I \ SUMPS LI Distance to nearest: Well Foundation Property Linej h DISPOSAL PONOS 0 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin;county ordinances, state taws, and rules and regulations of the Sen Joaquin County j a 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 perlormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applica ust call for fl required inspections. Complete drawing on reverse side. Signed Y �A...t �.(��vr 1J1�.-t Title: res i4 Date: ✓C� 1� Z QR DEP RTMENT USE ONLY100 ryT 3 Application Accepted by Date Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ,I - Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2008, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT No. INFO CASH • £M 1321(REV. SO 1i em [3.24 c/a U i, 0O L �' '„ � to-14"L-yZ `7Z,3 W 0 a o73�z. /yew.//Qn,i;�; .