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�r SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION !f 45 N SAN JOAQUIN, PHONE (209)46$-3420 I P 0 BOX 2009, STOCKTON, CA 95201jar p ERMIT EXPIRES 1 YEAR FROM DATE ISSUED lJ (Complete in- 'Iriplicate) Applica on is hereby made.to -San Joaquin Co ty for a pe mit o c struct and/or install the work herein described. This ith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San application is made in compliance w Joaquin County Public Health 04 ��-j2y � S,WN k7d City Lot Size/Acreage Xob ass J (p 3 Phone Address r` Owner`s Name i L icense —Pham l-Address Contractor FMFNT&Y DESTRUCTION Out of Service Well ❑ NEW WELLt WELL REP OTHER © Monitoring Well C� O TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PUMP INSTALLATION ❑ r_ 1 '�`—` SEWER LINES ��— DISPOSAL FLD. POOP. LINE DISTANCE TO NEAREST: SEPTIC TANK �----- AGRICULTURE WELL `�^ OTHER WELL `^ PITS/SUMPS FOUNDATION -- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Cas'n p Open Bottom ❑ Manteca Dia. of Well Excav tion: n industrial � cifications Tracy Type of Casing-- ` •Cl domestic/Private- �hGravel Pack Depth of Grout Seal T pe of Grout y L] Other n Delta 'VI Public i. SAAce.SeaYlnstaRed_pt t rn at50n - Approx. Depth l I Eastern �k4J State Work Done S� H.P. rs_� CvrYI Repan,V+lork Done L7 Type of Pump _ ' �� Sealing Material & Depth.�1 a'D f s� , F& - a Well Diameter 6D Well Destruction / Filler Material 6 Depth Sa k [ f Depth10 -jTYPE OF SEPTIC WORK; NEW INSTALLATION l 1 REPAIRIADDITION I I DESTRUCTION l I availabletlwit hin 200 feet.) it public sewer is Installation will serve: Residence— C!Amerciai_Othe _T Number of living units: Number of-bedrooms - Water table depth I Character of soil to a depth of 3 feet: r , Capacity No. Compartments E �SEPTIC,TANK- C3Type/Mfg Method of Disposal PKG.'TREATMENT PLT. ❑ Foundation Property Line -- j Distance to nearest: Well ` Total length/size LEACHING LINE Cl No. & Length of lines, Foundation Property Lina — ` !FILTEfl BED Cl Distance to nearest: Well _ I I Depth Sire Well Foundation Prop Number a SEEPAGE PITS e Property line SUMPS' LI Distance to nearest: i. t DISPOSAL PONDS '❑ ' ` �'`'� p I hereby certify that I have prepared this application and that the work will%be done in-accordance with San Joaquin county ordinances, stale laws, and rules and regulations of the San Joaquin county `�, f$� j Hama owner or.licensed agent's signature certifies the.following; 'I certify that 1n the performance of the work for which this permit is issued, l shad 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 cenifies the following: "!certif hat in the performance,of the work for whicplay persons subject to workman's compensa h this permit is issued, I shall am 'tion laws of C a." The applic ca ora requir i S. Complete drawing on re side. 1 Title: Date: Signed X r { FOR DEPARTMENT USE O Y t i t Date Area SCJ I Application Accepted by I I Pp�. �P .� �f�• �` j i Fin I Inspection y Date 'Pit or?Grout inspection Date I Additional Comments: 1 1 ` Applicant - Return all o es o: a oaq i C unty ubc ealth Services �a-+T�: 4� _ /(pt7 C uvironmental Health Permit/Services _ � 6 C-o • ' T {A)LE-c<. �dIGr4 u Z � 4�45'N 'Sa'a Joaqu'i'n;p'O'-Box-2009-,--Stkn,CA• 9520 _ _ _ .-�-CK' -'-- °.'•"`--'..,'�}- . PEiiMIT'N0. "FEEAMOVNT Dt1E_y AMOUNT REMITTED CASH £CEIVED By DATE INFO I EH 13-24(REV.t/MSI I EH 14-26 1, a