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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT 'F IRES 1 YEAR FROM DATE ISSUED (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 No. 549 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. ] Job Address 21863 N L3211P_Q City 1Q r ren n Lot Size/Acreage } +1 Owner's NameflazaaLi Nagata Address Mme Phone 369-6044 ContractorC-eank Address 2024 6. Chci_lt f—lz License No.3 7 15 G U phone 4 -7 TYPE Of WELL/PUMP: NEW WELL ❑ WELL REPLACEMENTS DESTRUCTIOf+IXIxOut of Service Well 0 PUMP INSTALLATION-)E)C SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK .£4Cltlr�_! SEWER LINES DISPOSAL FLO. PROP. LINE r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation 9�" Dia. of Weil Casing 6 5n ,4� .@omestic/Private kl,fPravel Pack7 ❑ Tracy Type of Casing_. K J,2 a Specifications4-41- F] 41-1'1 Public El Other 11 Delta Depth of Grout Seal )(I() Type of Grout-,Q 4 ! I Irrigation Approx. Depth I ) Eastern Surface Seal Installed by�. ('��_ OQ Repair Work Done U T f p Type of Pump _ � H.P. n v Q _ State Work Donet„ta g t.g, Well Destruction ❑ Well Diameter _ (z; Sealing Material 8 Depth ne Qe � Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION i I lNo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial e Other Number of living units: Number of bedrooms Character of soil to s depth of 3 feet: Water table depth C SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments, ` PKG. TREATMENT PLT, ❑ Method of Disposal f1D Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Wet] Foundation Property Line \ SEEPAGE PITS 11 Depth Size Number SUMPS L! 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 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 cartifies the following: "I certify t in t rice of the ork for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applican f I qu d ' c m ate rawing on reverse side. # Signed X 7iNe:V/� C Park ll In Date: _2 Zorz 9 FO DEPARTMENT USE ONLY Application Accepted by Ari,, % Date 25— Area Pit or ro InspaciioJn by T Data r Finat inspection by Date ' 3 Additional CommentJ:-491 Applicant - Return all copies to: San Joaquin County Public Health Services 7�, Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201. LFE AMOUNT Dt1E AMOUNT REMITTED ASRECEIVEp 9Y DA7f POO EN 13.241REV.t/p5) 4 EN 14-20 ¢ D� ;