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4 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES \� ENVIRONMENTAL HEALTH DIVISION 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 installtheorlC �ibed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1$62 and the Rules and iiegulations of San t x_ Josquin County Public Health Services. Lo-_ o/ RecolLd Job Address 1, rte __ City —_ hot. Size/Acreage ZZ Eddy flLe LCLRO /Address Owner's NartePhone 9..3-.�.. Contractor Ua lEk HeU Address License No. 3 7 9�4lj5 Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENTS DESTRUCTIONXqOut of Service Well ❑ PUMP INSTALLATIONr2 SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well- DISTANCE TO NEAREST: SEPTIC TANK 7 5 ' SEWER LINES DISPOSAL FLD. PROP. LINE 75 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS — # t INTENDED USE TYPE OF WELL r PROBLEM AREA CONSTRUCTION SPECIFICATIONS t Cl Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation_ Z 1" Dia. of Well Casing n kj1CDomestic/Private xq�aravel Pack ❑ Tracy Type of Casing_ Step P Specifications,. - - I'I Public , `l:7 Other (l Delta Depth of Grout Seal ^ '() Type of Grout 2 ,4 a a 11 Irrigation A"r* _.Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump �119 --- H.P. State Work Done _ Well'Destruction O Well Diameter �" Sealing Material & Depth A,;44 0,... .F _m �6v 9 hack Depth 15 6 g Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION l I REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number"of bedrooms Character of soil to a depth of 3 feet: Water table depth " SEPTIC TANK.,, 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Sire Number SUMPS Ll 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 y employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature 1 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 applican s all r eq "r i Pe to C plate drawing on reverse side. Signed X Title;V/� Lea zk ll Date: 22 cgp4 � 2 F R DEPARTNEENT USE ONLY c� + Application Accepted by �' -�► `ria t Date 12-- Area I Pit or4r Dlnspection by Date r�b Final Inspection by Date Additional Comments: a I Applicant -'Return all copies to: San Joa in County Public Health S vices Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. ' INFO CASH lye . EN 13.24(REV."1iNssv,D ! EN 11•�a Y5• 0O