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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION . 445 N SAN JOAQUIN, PHONE (209)468-32420 FFA P 0 BOX 2009, STOCKTON, CA 95201 461-01_36 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. b", nd 1 62�grcd the Rules and Regulations of San Joaquin County Public Health Services. D� (�N�]�3 r Job Addlress y—�N►/ 1 E! City Lot Size/Acreage + �lh ��• I L , Owner's Name 1 ' ' cAxftry' '""r_ Phone I (Contractor A Address^l�0 6UM/U At/ License No. )-93q'18 Phone 0)a x+58 ,TYPE 01= WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ � SYSTEM REPAIR L7Monitors OTHER ❑ ng WellC7 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 4 CONSTRUCTION SPECIFICATIONS '❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Welt Excavation Dia. of Well Casing ;C.i Domestic/Private 0 Gravel Pack ❑ Tracy !Type of Casing_ Y - Specifications I'1 Public. Cl Other n Delta Depth of Grout Seal Type of Grout fl I Irrigation —,Approx.'Depth I ) Eastern Surface Seet Installed by Vt Repair Work Done ❑ Type of Pump H.P. State Work Done t:- Well Destruction O Well Diameter Sealing Material & Depth Depth Filler MaterlU Depth . ¢TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION I I (No septic system!permitled if public sewer is :. available within 200-feet.) ' Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms r Character of soil to a dept f 3 feet: p Iq oe A g Water table depth SEPTIC TANK. Ir Type/Mfg 4 apacity No. Compartments PKG, TREATMENT PLT. ❑ f�A f ACIE )Zeotw(s -7 7,Wk__ Method of Disposal � r Distance to nearest: Well Foundation Property Line `- i 9 S LEACH114G LINE Cl No. & Length of lines Total length/size FILTER 13ED r ❑ Distance to nearest: Well Foundation Property Line 73 1 SEEPAGE PITS 11 Depth _ Size Number SUMPS L-I Distance to.nearest:'--'•Welt - Foundation Property Lina DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done;iiti.sccordance with San Joaquin county ordinances, state laws, ander rules and regulations of the San Joaquin County t r-e Home owner or licensed agent's signature certifies the following: "I certify 16t-6n the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the pe rman.ce of the work for which this permit is issued, I shall employ'persons`subject to workman's compensa- tion laws of California." r:, � The applicant must call for all re ad ins ctions. Complete drawing on reverse side. G »_ Signed X �1 Title: ' -,.Date: 1 o 1 m Al Z FOR DEfARTMENT USE ONLY q Application Accepted by `-"'C. .. i� -+.�.,. Date Pit or Grout Inspection by Date Final Inspection by '2 Data l0 Z! Additional Comments: n Applicant - Return all copies to: San Joaquin County Public Health Services d Environmental Health Permit/Services ..T 445-N•San-Joaqu-i-n—.P-O,Box-2009;-Stkn,-CA-85201 FEE INFO AMOUNT DUE AMOUNT REMITTED .CK, R CEIVED BY OfTE PERMIT'NO. 4f , 5�. . EK 13.2 tNEV. i n 51 l `� fH 14•ab i