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5Tc PH5 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete "in Triplicate) Application Is hereby made to San Joaquin County for a permit to construct and/or instali 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. j l25� WAY, Q s City 5 �'� Lot Size/Acreage y� Job Address r_ O'c"5sCo C �1 tYfllt Owner's Name t � -P ss � rut!$�w�-t--�+ 3��Jd� -- Phone Contractor eG v+'V► Address Z 28G � "" License No.! ii Pho 1� �- e71 TYPE OF WELL/PUMP: NEW WELL CI WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Wel1N Gl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES pb DISPOSAL FLD._ POOP. LINE FOUNDATION i2° AGRICULTURE WELL OTHER WELL tS�4 PITS/SUMPS Wtaiti. r INTENDED USE TYPE OF WELL- PROBLEM AREA CONSTRUCTION SPECIFICATIONS—, n Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing El Domestic/Private Gravel Pack ❑ Tracy Type of Casing-54U � Specifications l• �.,� l'1 Public f 1 Other F-1 Delta Depth of Grout Seal � n? -- Type of Grout Ve ^P I I Irrigation 9fAoltitaT% Approx. Depth [Eastern Surface Seal Installed by Repair Work Done L] Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Depth Filler Material i Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ! DESTRUCTION I I (Nose ttic systithin m reneet.ted if public sewer is availaInstallation will serve: Residence_ Commercial_ Other 5 Number of living units: Number of bedrooms_ Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity— NoFF, PKG, TREATMENT PLT. ❑ y M Y osa Distance to nearest: Wel! Foundation Propertt 1I ED LEACHING LINE ❑ No. 8 Length of lines Total length/41nJNTY FILTER BED Cl Distance to nearest: Wall Foundation "C t1l0r1qrAi T� SEWICES ri SEEPAGE PITS 11 Depth Size Number SUMPS tl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS . ❑ I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, slate laws, avid - 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, f shall employ persons subject to workman's compensa- tion laws of California." The applicant II f r r r s coons. Complete drawing on reverse side. Signed Title: L41/ �ti2pLc,e I r 1 1 Date: ((Q k C ,� FOR DEPARTMENT USE ONLYtit Qom] Application Accepted by t Date =� C Area aZ Pit or Grout Inspection by Date Z Final Inspectionbyt Date Additional Comments: _" A . N 5A W`4 rl A - Applicant - Return all, copies to: flan Joaquin County Public Health Services p� Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 ! FEE AMOUNT DUE AMOUNT REMITTED I CK 8 CASH RECEIVED BY DATE PERMIT'NO. INFO �.f . EH 13.24 IREV.t/n SI g 00 ! all EH 14.26 - r1