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OLD SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � Q ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 C P 0 BOX 2009, STOCKTON, CA 95201 K PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDnf�j�, / o�Jlav (Complete in Triplicate) ;Z65Application is hereby (made to San Joaquin County for a permit to construct and/or install the work herein described. This application 1s made 1n compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of SaRic �• Joaquin County Publics Health Serviices.,,, (fib Job Address �/��/ At a&11Ale City Lot Size/Acreage Addres e, s /'7�� '` '- Phone && Owner's Name l Contracto l�'M S Address&5 Li rtGc�l� License No.� j b7z Phone 7 S ZOy TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT rT DESTRUCTION ❑ Out of Service Well O PUMP INSTALLATION,CY SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L� DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES DISPOSAL FLD/d&_ PROP. LINE FOUNDATION _ AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPEF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS CI Iu I pen Bottom ClManteca Dia. of Well Exca ion Dia. of Well Casing omestic/Private O Gravel Pack ❑ Tracy Type of Casing_ I Specifications I'] Public Cl Other n Delta Depth of Grout Seal Type of Grou -e,--,o, I , -,o, I I Irrigation �&Approx. Depth 11 Eastern Surface Seal Installed by �� Repair Work Done U Type of Pump � H.P. J— State Work Done_ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.I Installation will serve: Residence_ Commercial s 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.O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 workman'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 appliSSAwto call for uired inspections. Complete drawing on reverse side. / �j Signed Title: �L Date: �(.��lO 1 FO D RTMENT USE ONLY Application Accepted by Date Area--f-- Pito Grou Inspection by "t`W Date f1,130, Final Inspection by Date / Additional Comments: �✓1h^-e�`� a4i .MAGI �✓ Applicant - Return all copies o: San Joaquin County Public Heal Services c�b_lo`l gray �"� Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO A UNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PEr�RMI NO. . EH13.24(REV.1ins) w (• �- 7 ��ft"�Z (`�_ EH 14.20 CCC (( 1