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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES P� 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. ��Cityr ! �dt � ��- �` Lot Size/Acreage I� Y t /` Job Address I Rj�L�("� 1-•!`�l, C u`JP� Phone Owner's Name P�3S' QII Address 2�s _ / �+ (/1f�(]�� 7�vT` 4AJ License No"`y.� �1 Phone Contractor + • r" r ` ' T' 611?d6ress 1 of Service 11 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L1 �t Monitoring Well ❑ PUMP-INSTAL-L.ATIONrtg SYS.T.EM_REPAIR,C . c. OTH.EFt❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial C1 open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_ Specifications b F Public la Other n Delta Depth of Grout Seal Type of Grout .-.� I I Irrigation ..Approx. Depth I I Eastern Surface Seal Installed by � H,P., State Work Done. I Repair Work Done U Type of Pump j , . ,r ., v. tQrA Sealing Material & Depth Well Destruction ❑ Well.Diameter -�F'iller�Meterial & Depth. Depth_N; ."--��, TYPE OF SEPTIC WORK: -NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I aNjlablpe�wRfiirr2l]0 feetc system .) if public sewer is -�- L 7 s Installation will serve: Residence_ Commercial Other k Number of living units: A_ Number o;f bedrooms Character of sail to a depth of 3 feet: 4L CA/hWater table depth SEPTIC TANK. O ,Type/Mfg Capacity No. Compartments i f "4. T Method a tsposai PKG. TREATMENT PLT. ❑ ' w t jDistance to nearest: Well Foundation ��• Property Line 1 LEACHING LINE C1No. & Length of lines — Notal length/size G FILTER BED {1 Distance to nearest: Well Foundation Property Line I f0 SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well y' f undation Property Line - . k DISPOSAL PONDS ❑ # } F- I hereby certify that I have prepared this application and that the work will ba 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, I shall not employ any person in such manner as to beco a subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "1 certify that in the pe rmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion laws of California." ti t The applicant I for all red ins tions. Complete drawing on reverse side. /� �,�� 3fY�i3 Signed X f'�^ F Title: -�L/�^'- "'"'� Date: R PARTMENT USE ONLY r PkA ri r�o Application Accepted by �/ ~ w. wcs Date 7, Area_ i Pit or Grout Inspection by f Date Final Inspection by Date`�� Additional Comments: j r Applicant - Return all copies to: San Joaquin County Public Health Services t ! f Environmental Health Permit/Services ,/ f 445.-N--San-JoagUI-n-y-P-,O,Box-2008-,-gtkn•,CAr95201 FEEAMOUNT DUE _ AMOUN-REMITTED CK RECEIVED By DATE PERMIT'NO INFO CASH . EH 1211REY.v/n51 I r •J �,�_ I IShh3L J 4 EH 71-4-2a ,t