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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 iKT7 _rera ZO-3y96-02. P- 0 BOX 2009, STOCKTON, CA 95201 S 1 6rut.,g l H LA-S pr'KK-its 1 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 7JHealth Serv��Lr� LJv •' City �� -� Lot Size/Acreage Job Address yaps- nf. ,Tt}rlc �r�tE aft , Owner's Name S) "s Address _ Phone ' Contractor, I.rfQ'L�+ dress Z i M T� ST License No. �rrZZ68 Phone yg�13 y TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll ❑ - PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER .0% 7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -----8 (�Qj2) j FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 10 IIV 20r to n Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation stag-- f:l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ie� 77L i`I Public is Other "f n Delta Depth of Grout Seal Zyle bOi Z- i I lrrigation —.Approx. Depth l l Eastern Surface Seal Installed by -Wry L u-I Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter € Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INos ptic systeshin m perf m tted it public sewer is availaInstallation 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal \ Distance to nearest: Well Foundation Property Line e LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS l 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 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 certifies the fallowing: "I cartify 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 ust call for all required inspections. Complete drawing on reverse side. Signed X Title: F 1 S Date: _1t9_7=!27_ OR EPARTMENT USE ONLY `/_ Application Accepted by Pate ` V r� .A- Area Pit or Grout Inspection by Date Final Inspection by Data 6 Z Additional Comments: Applicant —Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 PEE AMOUNT DUE AM N7 REMITTED I C INFO K EIVED 8Y D E PERMIT'NO. EH 13-24 IREV.i i r 5) 93L v EH 14.26 "'