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t SAN JOAQUIN,COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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 work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 4 mYgflly �.� City I- C7 Lot Size/Acreage ' Owner's Name f ALL is R/f/ Address Phone Contractorr/6o.ai tf SoA- Address A602 pt ✓�F'/r^j Ur' License No. T/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIONS❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR 11OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST; SEPTIC TANK SEWER LINES DISPOSAL FLD. 'PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT—ION-SPECIFICATIONS / n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1.1 Domestic/Private ❑ Gravel Pack7 El Tracy t Type of Casing_ - ' Specifications 1'} Public C1 Other 11 Delta r Depth of Grout Seat Type of Grout I i Irrigation Approx. Depth I I Eastern f Surface Soul lnsialled by Repair Work Done U Type of Pump H.P. ' State Work Done Well Destruction ❑ Well Diameter Sealing Material b Depth Depth Filler.Material &.Depth { TYPE OF SEPTIC WORK: NEW INSTALLATION/ REPAIRIADDITION 1.1 DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence— Commercial— Other j%b i tjq 14o r'7 v Number of living units: r Number of bedrooms f Character of soil toe depth o(3 feet: l&4Z;2f t_dgD ' ~'"4 � Water table depth S`p SEPTIC TANK G6 Type/Mfg t -Capacity �e No. Compartments PKG. TREATMENT PLT'. ❑ `fitMethod of Disposal Distance to nearest: _ Well S Foundation _j U Property Line LEACHING LINE 0 No. & Length'of lines � '` �S Total length/size FILTER BED ❑ Distance to nearest: Well Foundation J5- Property Line SEEPAGE PITS A Depth Sire .4e Number 2L SUMPS CI Distance to nearest: Well Foundation iPs 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 ' r 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." I i The applicant m t call for all required insaptions. Complete drawing on reverse side, Signed X Title; Date: /Zp- 2-- IF OR FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by "INA, Date Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services r 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 r ,INF AMOUNT DUE AMOUNT REMITTED 'CK RECEIVED BY DATE PERMIT'NO.'�. + EM 19.24 TREV.r/n51 � / 1 '17,3 � 4 EH 14.20 / /