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�~ SAN JOA@UIN COUNTY PUBLIC HEALTH SEE RVICS ENVIRONMENTAL HEALTH DIVISION �Z_ � 445 N SAN JOAQUIN, PHONE (209)46$-3420 �' P O BOX 2009, STOCKTON, CAM95201 ` , PERMIT EXPIRES 1 YEAR FROM DATE ISSUID (Complete in Triplicate) i permit to construct and/or install the work herein dlationsdof Sans. ' Applicntiott is'hereby made to San Joaquin County for a P 4 and 1862 and the Rules and Regu application is made in compliance vlth San Joaquin County Ordinance No. 5 9 Joaquin County Public Health services. _�„�,�,., '. Lot Sine/Acreage City wA Job Address Rhane °'Address Owner's Name K7 Nil?llOr T�Phone 1, 1 License No:. ri an[`e D! � ss DESTRUCTION Cl put of Service Nell ❑ I Coittrattor� SS =A` - WELL REPLACEMENT Monitoring Wel 1 C3 j NEW`WELL,Z OTHE .C1 TYPE OF-WELLIPUMP: SYSTEM REgA1R n PROP. LINE 0 PUMP INSTALLATION' f DISPOSAL fLO.�— SEWER LINES -- OTHER WELL�� PITS/SUMPS DISTANCE TO NEAREST:-SEPTIC TANK -- AGRICULTURE WELL .- FOUNDATION �--- L PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing INTENDED USE TYPE OF WELL 11 a.Manteca Dia. of Well Excavationd--- $peGilications ` D industrial 1 Open Bottom , steel CP1nPY1 I ❑rTracy Type of Casag- 6Q Type of Grout i! R Domestic/Private ❑ Gravel Pack rl Delta Depth of GroutfSeal � i� S-1 Other Surface Seal lnstalled by ;! I'1 Public ------------- ii irrigation 3� APprax. Depth I I Eastern 3 �, State Work Done H.P,Sealing Rapair Work Done L3 Type of PUMP Ste— Material 4 Depth Well,Destruction ❑ Well Diameter -� Filler Material & Depth Depth V available within 200 feet.l F SEPTIC-1NOftK:� NEW INSTALLATION I I_ REPAIRIADDITION i ! RESTRUCTION I i i+vo septic system permittedff public sewer is '` TYPE O Commercial — Other Iristaliation will serve: Residence� . Number of living units: Number Of,bedrooms , Water table depth t ' Character of soil to a depth of 3 feet: CapacityT�----� No. Compartments SEPTIC TANK ❑ Type/Mfg ,. Method of Disposal '`PKG. TREATMENT PLT. ❑ P_r.opertY_Lina_ Foundation-�--�- Distance� nearest „r,•WeAV I i -^ Total length/size LEACHING LINE CI No. & Length of lines = Line�---- f FILTER BED 0 Distance to nearest: Well_��. +.Foundation !�-- Property Number f I I Depth Size Property Lina�--- Z, SEEPAGE PITS Foundation��--- SUMPS LI Distance to nearest: Well��- � . ws, and DISPOSAL PONDS ❑ certify that I have prepared this application and that the work will be done in f ccardance with San Joaquin hich this permit isissuted late ashall not i_,hereby ce Y rules and regulations of the San Joaquin County ' I certify that in the.performance of the work o Home-owner or licensed agent's signature certifies the following: " nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa employ any person in such manner as to become eblQct to workman's compensation laws of California.' Contractor's hiring or sub-contracting signature Carl the following:'9 certif that in the performance t tion laws of California." 9/21/92 ` The applicant u call f r all squired irgpoptions. Complete drawing on reverse side.: OWIle / atOx Date: Cid"'�•--'C.- Title: Signed X r FOR DEPARTMENT USE jONLY € Date Area i Application Accepted by Gate�d` ! ural In spaction by Date � r� Pit or ro)inspection by Additions Comments: ith Applicant - Return all copies Eot4 gnvironmentalaHealthuPermit/Services vices p 0 Box 2009, Stkn, CA 95201 ' 445 N San Joaquin, . CKRECEIVED BY DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT RCASH EMITTED - ,L t INFO ��-aL 9a^ g EH 13.21 IREY, t/h5] u''� 3 o o 14Ca a2 � EH 14•2e _ - _- c