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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Y ENVIRONMENTAL HEALTH DIVISION { {� 445 N SAN JOAQUIN, PHONE (209)488-3420 � 1 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - N (Complete in Triplicate) I Application is here made to San Joaquin Count for a 1?� by q y permit to construct and/or install the work herein described. This t ,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. t 4- � -job Address CityLOA. Lot Size/Acreage Owner's Name DIA h L l'�,D INC Address v C Z Phone Contractor ft- Address Ff)•130Ni ,4fZA—L License fVo �-�Phone �P -�.� TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION`�YOut of Service Well ❑ PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER/❑_ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE FOUNDATION-L—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 Well Casing C_1 Domestic/Private ❑ Gravel Pack7 ❑ Tracy Type of Casing_ Specifications l Il Public 1-1 Other F1 Delta Depth of Grout Seal Type of Grout 11 Irrigation _,Approx. Depth I I Eastern Surface Seal Installed by ! Repair Work Done # L3 Type of Pump _ H.P. ate Work .D _ Well Destruction Well Diameter _ Sealing Material k Depth Depth Filler Material & Depth su TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is ! available wiihin-200 feet.) 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 1 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, D Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size f" r FILTER BED k ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 4 11 Depth Size Number y SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS, ❑ --. 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 ii7and re mations af'Ihe Sari 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 subcontracting signature certifies the following: '9 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 required inspections. Complpte drawing on reverse side Signed .d .Title: a ec date: 2�4 +� ` OR DEPARTMENT USE ONLY Application Accepted by ► Date— A _`_ Area Pit or Grout Inspection by Date Final Inspection by Date 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 FEE INFO AMOUNT DUE AMOUNT REMITTED GK T ASH RECEIVED BY DATE PERMIT'NO. • EH 13-24 tREv.I/n 5! /� (` EH 1J-20 vl 0 f� V V a ._ (/