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i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 A P O BOX 2009, STOCKTON, CA 95201 k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ! k (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 Ho. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. ."A , {{++ Job Address Z 1 J �' 1 City�? Lot Size/Acreage A L l Owner's Name 'L�ri �'' Address S� Phone 3 r Contractorel Lid C4bCS Address A License No.D)?X-V Phone33 Y' 97%.X TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT >e DESTRUCTION NZut of Service Well ❑ PUMP INSTALLATION De SYSTEM REPAIR D OTHER Q Monitoring Well �7 DISTANCE TO NEAREST: SEPTIC TANK ( '� SEWER LINES DISPOSAL FLD.tra PROP. LINE FOUNDATION AGRICULTORE"WEL`L LI� OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM/AREA CONSTRUCTION SPECIFICATIONS i n Industrial O Open Bottom C1Manteca : Dia. of Well Excavation Dia. of Well Casing Domestic/Private Gravel Pack ❑ Tracy ` Type,of Casing_ a0!f� Specifications F`YeP I'1 Public Cl Other Fl Delta Depth of Grout Seal de Type of Grout I I Irrigation Approx. Depth til Eastern y r Surface Seal Installed by co/k, rti Repair Work Done ❑ Type of Pump Sc.. H.P. f S State Work Done I Well Destruction ❑ Well Diameter p" Sealing Material & Depth C C-o0XV-,r Depth IIZV. ,;! 3 Filler Materietl & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted it public sewer is available within 2;X1 feet.] Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms "r� Character of soil to a depth,of 3 feet:_ r i 7 r Water table depth I i i SEPTIC TANK.."r,t,�, i❑ Type/Mfg } Capacity No. Compartments PKG. TREATMENT PLT. ❑ # ti '. Method of Disposal r � .,,g• •"' Distance to'nearest: ;Well Foundation Property Lina 5 j LEACHING LINE `❑ No. & Length of'lines Total length/size FILTER BED n Distance to nearest. Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS. "-Ll Distance to nearest:a 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 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 4 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 applicant must all for II required insPections. Complete drawing on reverse side. L f Signed X Title: AW Al dR- _._ Date: — L — 9 \- I FOR EPARTMENT USE ONLY e II Application Accepted by F , ^� Date �•— Area II Pito Grout speetion by Dater 9 Final inspection by Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box.20O9, Stkn, CA 95201 .1FEE Z qL ,kN'F+O AMOUNT DUE AMOUNT REMITTED CK- ECEIVED BY p E PERMIT'Np. • EH 3.2{IREV.i i n s> twf— EH 1{•2a 1 't'P_ M