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91PPL-IC-ATTON SANOAQUIN COUNTY PUBLIC HEAL, ERVICES ENVIRONMENTAL HEALTH DIVI I N 445 N SAN JOAQuiN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSIIID (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 is made in compliance with Sam Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of Sm Joaquin County Public Health Services. �L.�.� �-{-� Job Address Q2µ N . Von �(e 1n � City S` DCA ^_ 'r) Lot Size/Acreage /�I,� �j I,, 1 v berry sPyrr� I, �l5 G(ua. j Owner's Name ( L'Q-5� l_Y I�,V�(��SLI �1��. Address 4�,P,L. lHayl-1`�4SE Plwf,e 5't��k-FD rI 2021 - F74-N IS' Contractor .5 p6u_r A-t-h" Address r�-� 25 C �y�- -� License No.EL12G Q Phon � 6x'871 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ Soles V3oHER5_3Monitorie]15 DISTANCE TO NEAREST: SEPTIC TANK N A SEWER LINES DISPOSAL FLO. `I`/A PROP. LINE 1� FOUNDATION 7 1 Ob AGRICULTURE WELL _Li OTHER WELL p -0U PITS/SUMPS J_ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rt C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I Dia. of Well Casing 71 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Tr4-RC) ?v C, Specifications f1 Public n Other rl Delta Depth of Grout Seal © - 20 I��A1r ceuNen ',q p Type of Grout I I Irrigation [=ZAPpos. DepthEastern Surface Saul Installed by SPCCnn "u YYI Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction �❑j Well Diameter Sealing Material i Depth Mbn l{brl Vt( 1. Depth Tiller Material i Depth TYPE OF SEPTIC-WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I Mo septic system permitted if public sower is available within 200 last.) Installation will serve: Residence_ Commercial_ Ocher Number of living units: _ Number of bedrooms Character of soil to a depth of 3 fast: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lina LEACHING LINE ❑ No. 6 Length of linea Total length/size VC' FILTER BED ❑ Distance to nearest: Well Foundation Property Lina SEEPAGE PITS I I Depth Size Number _ SUMPS LI Distance to nwrest: Wail Foundation Property Line DISPOSAL PONDS ❑ I hereby comity that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, stats 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 laws of.Calif Mo." Theapplicant call for all requir Osp cti hs. pttlt. drawing on reverse side. /p ✓Signed Title: IZG SO,,Z � Date: C// � F05 DEPARTMENT USE ONLY Application Accepted by Date `� < Area Pit or Grout Inspection by Oats [ Final Inspection by Date Additional Comments: /l-,21,1 � I 1I22f3917Dd�, In//)2 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Hos 2009, Stkn, CA 95201 INFO FEE AMOUNT DUE AMOUNNTT/R!%EMITTIED CK isCASH" RECEIVED BY C DATE PEE,RMIT'NO./ . EN ,s:4 uEw.t/4e, �Cf — V / �SSC7 Z/ f EN,4.76