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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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 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. %2 _-72 p 6 2Q C o 2 Job Address 2R�U6;i e � City Lot Size/Acreage Owner's NameLayeAne Artr1 r, _ Address A Q Ing Phone Contractor Uazk Np_,U, In"Address 2024 E. Chrl't- ,z 1daYLicense No371560 Phone 462-7676 t Out of service Well 0 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C$ DESTRUCTION )�I I PUMP INSTALLATION ADC SYSTEM REPAIR 0 OTHER ❑ Monitoring Well r DISPOSAL FLO. PROP. LINEl-44! #J DISTANCE 70 NEAREST: SEPTIC TANK �� . SEWER LINES -�--- M FOUNDATION AGRICULTURE WELL OTHER WELL ' PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS"I a Ll Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ZZr Dia. of Well Casing n Domestic/Private k1xGravel Pack L1 Tracy Type of Casing- P VC Specifications C:-( -00 - l'1 Public 1-1 Otter ❑ Delta Depth of Grout Seal 100 - -- Type of Grout O� I I Irrigation 21i0 Approx. Depth I I Eastern Surface Seal Installed by I/r1n k Repair Work Done LTC Type of Pump SU k _ H.P. I , State Work Done, . 6 f ci 0 0 00 Well Destruction } Well Diameter r-_ Sealing Materiel & Depth 9 A a r k A a a_.g.n I Depth l Filler Material & Depth -- �'— �—t�ttr^-�s 7L 4 _ TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTION I i (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence — Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments l PKG. TREATMENT PLT. C] Method of Disposal y Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation Property Line --- SEEPAGE PITS 11 Depth Size Number SUMPS L) 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, E shall not employ any person in such manner as t ame bject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I Certify that in parlor n f he wo for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Calif nla." The applicant I f r r it ins c o C e r ing on reverse side. Signed ley/1 C.(a.zk I)PJ 2 Date: 7 R .Sv¢>z 41-FOR DEPARTMENT USE ONLY Application Accepted by Date �L --..... Area _X evk� Pit Gro nspsction by Date Final Inspection by Dsts ' Additional Comments: Applicant - Return all copies to: San Joaquin County Public Heald Services Ad AN"` 9 Environmental Health Permit/Services I � 445 N San Joaquin, P o Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE P Mt7'NO. �� • EH 13.21(REV.t nsi � 13 EH 11.26