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OLD SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES JIMM ENVIRONMENTAL HEALTH DIVISION �bv 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 411%' 'ED ,�] ffd�P6 �llcJ�f1 (Complete in Triplicate)AppllcIs 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 �n Joaquin County Public /fHealth �Services. „ ,fpbCµ' P Job Address �/.(LL—L?_ u1�1 � City Lot Size/Acreage AcKwe Owner's Name & :. Address �� J Phone 3&7- IY2Z Contracto - 1/K S Addfess&53 Ali LJrtC61^3 License tic. - Phone 5 ZOV TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT 1r DESTRUCTION C1 Out of Service Well n PUMP INSTALLATI N SYSTEM REPAIR C7. OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD/6- PROP. LINE 6V FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYP F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f--J Indu l pen Bottom © Manteca Dia. of Well Exca ion Dia. of Well Casing omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ m_ Specification s4 y:_ i'l Public f_1 Other n Delta Depth of Grout Seal r Type of Grout , I l Irrigation g• a.�Approx. Depth i I Eastern Surface 5ea1 Installed by ,.p� Repair Work Done 0 Type of Pump �+' H.P. -Z State Work Done Ol Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION l I iNo septic system permitted if public sewer is available within 200 feel.I Installation 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 '1 LEACHING LINE C1 No. & Length of lines Total length/size / 'Z FILTER BED n Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 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 : t_ Y 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 taws of California." The applic tis call tar wired inspections. Complete drawing on reverse Bids. Signed Title: LL9lLPA� Date: / G FO D RTMENT USE ONLY Application Accepted by Date r Area Pit 01Eu Inspection by t� Date 1( 3 Fins[ Inspection by Date Additions! Comments: � L`� �� 1 Applicant - Return all copies o: San Joaquin County Public Heal Services Environmental Health Permit/Services 7~ �" ^ 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FI,FEE A 76UNT DUE nE1AMOUNT REMITTED CK RECEIVED BY DATE/y PERMI NO. . Eli 13.21IREV.rixsi W (J /' V V 3 6 l L �1 �r( Z ��—� EH t�•1a L