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I _ _ SAN JOAQUIN COUNTY{PUBL-PC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION ' 1 445 N SAN JOAQUIN$ PHONE (209)468-3420 P O BOX 20092 STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED I I . (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. Pr i r r Job Address _,f?��Z 6 t City y Lot Size/Acreage �- 'L Owner's Name z I " 7k Address yam` " Phone �vY Z1 � p. Contractor �� s Address �d , u��( License No.�n3 Fr Phone 4'"V7 TYPE OF WELL I` NEW WELL WELL REPLACEMENT M DESTRUCTION Out of Service well ❑ PUMP INSTALLATION Pe SYSTEM REPAIR ❑ OTHER ❑ I Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.ILINE F „F FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � ! . n Industrial ❑ Open Bottom ❑ Manteca Dia. of'Well•Excavation Dia. of Weil Casin 6 kDomeslic/Private !Gravel Pack ❑ Tracy Type of Casing_ �� •Specifications S, T A-+. e Cl Public is Otheyyr„��. / ❑ Delta Depth"of GroutxSeal � `Type of Grout CC/J�y f- g' �'h pip/x:� p A �. I ! Irrigation A De th 1 I Eastern Surface Seal Installed by ��"' Well it Worct one Type' tPu mp � H.P. _ tate WoWDone 0� Ih � ;- s gyp, I Sea-ling Material & D` th 4-CC 1 i3 ~V } `• r P DeptfT Filler Material A Depth.;, M TYPE OF SEPTIC WORK: NEW INSTALLATION.I I REPAIR/ADDITION I I DESTRUCTION i I (NO septic system Oernttlscl if public sewer is , available within 2004.pq PI Installation will serve: Residence T 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,❑ �� y _ - -..�. �.r �. TM Method of—Disposal! Distance to nearest: Well Foundation k- ._�-.property Line { LEACHING LINE. ❑ No S Length of lines Total length/size FILTER BED ❑ DI�tande-to`nearest: Well Foundation Property Line —pzz�', SEEPAGE PITS l I Depth Size Number SUMPS -LI Distance to nearest: Well Foundation Property Line k DISPOSAL PONDS ❑ Ip i 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 thii permit is issued, I shall not employ any person iri such manner as to become subject to workman's compensation laws of California." Contractor's hiring`or subcontracting signature E cartifies 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 applicant must call for all taquired inspections. Complete drawing on reverse side. ._ Signed X Title: &C:,jAAJt. _._,...._ Date:;?~LO ��. O -f'"VFARTMENT USE ONLY 1 Application Accepted by I' 1; DateArfi ea Pito rout apection by Dat� Final Inspection by D to Z -r IM Additional Comments: �' aE.r�, � � f.� 'ds - e�� Ec$/ /�� ' . rtoo�' Hrin o Public li'plicant - Retu all copies to: SanlJoaquin County Health Services � •Mr Environmental Health Permit/Services II� 445 N San Joaquin, .P O Box 2009; Stkn, CA 95201 rl< IEEEA AMOUNT DUE AMOUNT REMITTED CASH RECEIVED`BY DATE PERMIT NO. + EHti.EM 24(REV.riH5) �� rO l !Z Z„ t J nr o --` C . �N q z cQJ°el1 J