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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 Il 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 vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 3 0 i- e Crty Lot Size/Acreage <q, 0 4C, ` Owner's Name A;To I� _.A Address 12 0&�('7 !V �� ft-r e-S VZA Phone x Contractor V � liAddress DI --')- License NoPhone -TYPE Qf-WELL/PU11IP:�^-'^'� - N WELL❑ WELL-REPL-A•C-EMENT -; -�--_pESTRUC-TIONX-Out,of Ser-vice.Well ❑ PUMP IiNSTALLATION SYSTEM REPAIR ❑ OTHER C Monitoring Well C3 r DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLD. PROP. LINT 30 l FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 626e, INTENDED USE TYPE bF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS ❑ Industrial Open'Bottom ❑ Manteca Dia. of Well Excavation _� Dia. of We Casing C) Domestic/Private ❑ Gravel Pack E Tracy Type of Casing e I Specification's ,p i'1 l Public C7 Other Depth of Grout Seal rType of out Irrigation rsQ.Approx, Depth l I Eastern Surface soak Installed by r Repair Work Done 0 Type of,Pump 6 _ H.P. t� State Work Done ArL II Destruction ❑,r Well Diameter Sealing Material i Depth „_ [ pepth ?f -'^"'-Killer-!Material 3 Depth � TYPE OF SEPTIC W RK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted it public sewer is j IIavailable within 200 feet.) } r Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms ^ ; Character of soil to a depth of 3 feet:Ili Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ 11 Method of Disposal Distance to nearest: Well Foundation Property Line 1, r ' LEACHING LINE ❑ -No. i�Length of lines Total length/size FILTER BED n Distance to nearest: Well Foundation I Property Line hM �� SEEPAGE PITS I I Depth) Size Number SUMPS LI Distance to nearest: Well Foundation *' Property Line DISPOSAL PONDS ❑ I hereby certify that I hove prepared kthis application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and V 1 rules and regulations of the San Joaquin County Home owner or licensed agent's aigriature certifies the following: "I certify that in the performance of the worts for which this permit is issued, I shall not employ any person in such manner a`s to become subject to workman's compensation laws of California r, hiring or sub contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, t shalt employ persons subject to workman's compensa- tion lows of California." Us applicant must call r all r vire inspections. Complete drawing on reverse side. Signe Title: fZ C_�'S.� Date: . TR-DEPA-RTMENT-USE-ONLY ) Application Accepted by Date aT� Z- Area.' Pit or Grout Inspection by Date X23 ck 2_ Final Inspection by Gate Additional Comments: d r J Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services f0-io"?)-Q� 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNTREMITTED CK ECEIVED BY DATE PERMIT'NO. . Ens 13-24(REV.r i ai EM 16ZE 161 - � o7