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SAN JOAQUIN Cot NTY PUBALTHEALTHALTH SERVICES t ENVIRONMENTAL HEALTH 'S 445 N SAN JOAEQUIN, PHONE (209)468-3420 Nd P O BOX 200, STOCgTON, CA 95201 6 PERMIT FXPIRES 1 YEAR FROM DATE ISSUID (Compete in Triplicate) Application is hereby made.to Stas Joaquin County forermit to construct and/or install the work herein des a peribed. This application is made in compliance with San ,)oaquin County Qrdlnance No. 5k9 and 1862 and the Rules and Regulations of an Jc gain County Public Health Services I Lot Size/Acreage �\%Y1ODG gD Job Addres phone "l eT _ Address Owner's Name �sL� - 3 hone ` �.�._�.....,� ....•. -.. �_ �. _.- �� License No�� P f Address e O put of Service Well ❑ Contractor WELL REPLACEMENT 17 DESTRUCTION C7 NEW WELL ❑ OTHE (� Monitoring Well TYPE OF WELL/PUMP: �. SYSTEM REPAIR L7 PROP. LINE PUMP"INSTALLATIONT❑ DISPOSAL FLD. ` SEWER LINES -.�---- PITSlSUMpS �-- DISTANCE TO NEAREST: SEPTIC TANK �--- h OTHER WELL r--- t FOUNDATION �--- AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECtFICATiONS pia. of Well Casing ❑ Manteca Dia. of Well Excavation . 1 ❑ Open BottomT-,� Specifications Fl Industria Type of Casing C.1 DomesiiclPrivate ❑ Gravel Pack. P L7 Tracy Type of Grout ! 1 _ Depth of Grout Seal ` i'1 Public ` i 1 Other 0C 1 Delta pox. Depth_„I I Eastern F Surface Seat installed by A I i Irrigation H P State Work Done Repair Work Done L3 Type of fPump --- aSealing Material 6 Depth Well Destruction ❑ Well Diameter, --- - t � - - Filler Material 3 Depth Depth ^ - vaitable within 200 feei.! TYPE OF•SEPTIC WORK: NEW INSTALLATION lTl REPA�IRIADDITION { I DESTRUCTION INo septic system permitted it public sower is installation will serve: Residence— Commercial i Other — Numbe"of living units: Number of bedrooms k Water table depth Character of depth of 3 feet: Capacity Compartments ❑ I� SEPTIC TANK Method of Disposal PKG. TREATMENT PLT. ❑ Property Line ---- Distance to nearest: e F Ion ��--- r ! ! Total length/size LEACHING LINE Cl No. A Length of lines Property Line �-- FILTER BED ❑ Distance ton Well I� Foundation r � t at Site��' Number # SEEPAGE PITS 11 pth Foundation property Line SUMPS I Distance to nearest: �-�--- DISPOSAL PO ❑ I hereb rtify 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 €l I certify that in the performance of the work for which this permit is issued, I signature shall not k Home owner or licensed agent's signature certifies the fotiowing: " sub employ any person in such manner n the rto mance ofothe work for chethis permit is issued, I shall employ nsation laws of Califor �a,- apersons rsubj subject to orkman-contract'scompsnsa certifies ttie following: "I certify t Pe tion laws of California." I The applicant must call for all required inspections. Complete drawing on reverse side. Date: Title: Signed OR PARTNT USE ONLY ]_ t * r _f Datef - Area 1 ate Application Accepted by ` _ �� - r Date�.�..-.--- Final Inspection by Pit or Grout Inspection by r Additional Comments: ty Applicant - Return all copies to: San nJoaquinEnvirlOHealth uPexmiblic H/ Servicesealth vices 445 N 'an Joaquin, P O Box 2009, Stkn, CA 95201 k CK RECEIVED BY ATL: PERMITNO. FEE AMOUNT Dtlt AMOUNT-REMITTED CASH t. �r INFO 1 EM 13-24 iREv.I i w 51 EM 14.26 F�.