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SAN jOAQUIN COUNTY -PUBLIC HEALTH SERVICES a ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468--3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EgpIRES 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 here in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of an � Joaquin County Public.Health Services. 45- t /10Q44L 1A([dt,i KOAQ City ! � Lot Size/Acreage 0 S, C.. I � r Job Address 3 C04ne K MciaAw 4_^J- r_1 U_ q .SAFE _-WA V t� I^�v�.+r 7 D E, f`�AZEr~Ti)r-1 AVe"LIE Phone Pus 09a f Address Owner's Name - 3rf_s�67 /� (,(,7O _Phone G!J/rCT SAddress� " '�� License No. �� �_y ontractor�� WELL REPLACEMENT C] DESTRUCTION ❑ Out of Service Well ❑ NEW WELL ❑, OTHER ❑ Monitoring Well C7 PE OF WELL/PUMP: SYSTEM REPAIR ❑ PUMP INSTALLATION.., - •SEWER_LINES_��---�— DISPQSAI-F LP ��P. LINE DISTANCE TO NEAREST: TANKr _ — WELL OTHER WELL— FOUNDATION ELL �� PITS/SUMPS AGRICULTURE WE FOUNDATION , - _ INTENDED USE TYPE OF WELL PROSLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Open Bottom . ❑ Manteca Dia. of Well Excavation D Industrial Specifications f, ❑ Tracy Type of Casing_ �T [_} Domestic/Private G1 Gravel Pack r Type of Grout + Cl Delta Depth of Grout Seal � i•l Public 1.1 Other Surface Seal Installed by I i Irrigation Approx. Depth 1 I Eastern i State Work Done — ' Repair Work Done L7 Type at Pump H.P. (:jSealing Material & Depth Well Destruction O Well Diameter ----- Filler Material S Depth Depth available within 200 feet-1 TYPE OF SEPTIC WORK: NEW INSTALLATION 17 REPAIRlADDITION—TION DESTRUCTION I 1 (No septic system permitted it public sewer is Installation will serve: Residence— Commercial— Other �---- a Number of living units: Number of bedrooms Watyeerr table de th I Character of soil to a depth of 3 feet: Capacity-- Na.sCW 4 SEPTIC TANK 0 Type/Mfg MeRff PIW (� PKG. TREATMENT PLT. ❑ r{ Foundation Property 4,}[Att ��` Distance to nearest: Well i I H ! Total langth)i JOA JU4�% CO'UINTY LEACHING LINE L❑ No. & Letigth of linesI+ - i l Distance to nearest: Well Foundation r 1L �iV�S40N FILTER BED Size Number s w SEEPAGE PITS 11 Depth n W11eliFoundation. Pro Party Lr sumps..._.. _w T LI Distance to nearest: -- ;: s r DISPOSAL PONDS ❑ . I hereby certify that I have prepared this application and that the work will be done in accordance wi , and th San Joaquin county ordinances, state laws rules and regulations of the San Joaquin "Cour y g• work for l not Home owner or licensed agent's manner iignature certifies become subject f lto wrorkman'srtcompensation laws of Celftfniahe Contractor's thir ng or sub-contracting this permit is signature employemploy any person in certifies the following: "I certify that in the parlor msncs of the work for which this permit is issued, I shall employ persona subject to rkman's compensa tion laws litornla." The ap licant m st II for It J[t§pections. Complete dewing on verse side Date: S�S` Title: � Aigned . • EOR DEPARTMENT USE ONLY r i t Date 2— Area •L!fv Application Accepted by Date�L Date�--- Final Inspection by ' Pit or Grout Inspection by Additional Comments: t San Joaquin County Public Health Services Applicant - Return all copies to: Environmental Health Permit/Services _ 445 N San 'Joaquin, P. 0 Box. 2009, Stkn, CA 95201 =; FEE AMOUNT DUE 'AMOUNT REMITTED GK RECEIVED 8y DATE jlIMI1N0. INFO . EH 13.21(REV.tinS) P� ...•�,('�1�-�� 6�+x� � yvZ r� � X� L� � *EH14"28 1