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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-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 lO I1 l " :)� City Lot Size/Acreage < Owner's Name Address 0 Phone i 2- k toll �tt �7� cs7yB234D C Contractor Address License No. Phon a �� ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service We11 PUMP INSTALLATION ❑ SYSTEM REPAIR t.7 OTHER Monitoring Wyell DISTANCE TO NEAREST: SEPTIC TANK ��30a SEWER LINES > _ DISPOSAL FL PROP. LINE F FOUNDATION AGRICULTURE WELL � _tOT_ff_EA WELL PITS/SUMPS "'A' 4�`k INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUCT)%/SPECIE ATIONS rt n Industrial ElOpen Bottom ElManteca pia. of Well E ca tion Dia. We mg _ 1 FI Domestic/Private Gravel P ck Tracy Ty of Ca ' g Specific on 1 Il Public Other ❑ Delta Depth rout Sea ype o Gr I I Irrigation _ prorr, Depth l I Eastern Surfac Sau fist led b f Repair Work Done U T omp H.P. St a Wo r ne — Well Destruction ❑ _all Diamete Sealing Material & epth ' Depth Filler Material & Depth k TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.1 Installation will serve: Residence Commercial— Other `1. Number of living units: 4�Number of bedrooms 1/1 Character of soil to a depth of 3 feet: Water table depth 1` SEPTIC TANK. O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal /0 Distance to nearest: Well Foundation Property Line f I / LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance to nearest; Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI 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 workmen'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 applica ust call for all quired inspections. Complete drawing on reverse side. .7 Signed g Title: L� A:I �— Date: FOR DEPARTMENT USE ONLY I Application Accepted by ._. __.._ Date C Area Pit or Grout Inspection byr __ - Date 1113 q'Z_ Final Inspection by - , _ Date Additional Comments: U" l W Applicant - Return all copies to: San Joaqua County Pu is Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Sox 2009, Stkn, CA 95201 INFO AMOUNT OVE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT NO. . EH 13-24 IRtw.t/n51 A� 0 � EH 71.20