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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 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 vork 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. Jab Address A A50 AkI City 5 Lot Size/Acreage Owner's Name Address Phone Contractor G soe Address GOO.Z J?4,VeVVAI AL140. License No. �yy:rPhone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION C SYSTEM REPAIR ❑ OTHER 71 Monitoring Well ❑ 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 ' ❑ industrial ❑ Open Bottom C3 Manteca Die. of Well Excavation Dia. of Well Casing F} Domesticl Private ❑ Gravel Pack L] Tracy Type of Casing_ Specifications I1 Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx, Oepth I 1 Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done_ 9 Well Destruction ❑ Well Diameter Sealing Material & Depth www/"111 Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATIONX REPAIRA.ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is Q available within 200 feet.) Installation will serve: Residence_ Commercial_ Other 1 obd ROMP Number of living units: ' Number of bedrooms 3 Character of soil to a depth of 3 feet: - Water table depth SEPTIC TANK 0 Type/Mfg P3'a C".4s7' P>< L Capacity-J-2 o No. Compartments 2, fi PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line Z17-0 LEACHING LINE rii No. & Length of lines �Lbaas Aoc Total length/size FILTER BED ❑ Distance to nearest: Well -500/4' Foundation JD` Property Line 6 oO ' SEEPAGE PITS 11 Depth Size Number SUMPS L1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify 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 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 become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant must 11 for all required inspections. Complete drawing on reverse side. Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date /0 � 'f Z Area Pit or Grout Inspection by `` / Date Final Inspection by Data J� /�2— Additional Comments: ___AeQc�C_Ltn�t' la-ew- 96 [g O'�� Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 INFOFEE AMOUNT DUE AMOUNT REMITTED - CK III RECEIVED BY DATED QPERMITT''�NrO.. . EH112t1REV.IIK5) ,V !� I ��+V 1l r 7L r%b �G (2��7`CL EH w2a