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s ,SAN JOAQUIN COUNTY ,PUBLIC HEALTH SERVICES ENVIRONMENTAL- HEALTH DIVISION 445 N SAN JOAQUIN, P�bm (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 ?t119^1%10APO- PERMIT EXPIRES 1 YEARFROM DATE ISSUED 44, ;` ,. (Complete in Triplicate) �P 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 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Joh Address o J►n City L Lot size/Acreage ih Owner's NameAO Z0.1ACddfess �"'� Phone II' Contractor Addres A License N43 Q Phone -7 l 22 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ;,W OTHER ❑ Monitoring Well DISTANCE TO NEAREST:_.SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WFLL � PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS __� D Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia, of Well Casing F1 Domestic/Private Gl Gravel Pack L) Tracy Type of Casingte ^r Specifications O� \i l'1 Public �1 Other i 1 Delta Depth_of-Groiit'Seal r Type of Grout r_ k[irrioation —.Approx. Depth I I Eastern "'`"RSuriaee Seal Installed by •' eieele� Repair Work Done Type of Pump , H.P. State Work Don Well Destruction ❑ Well Diameter Sealing Material & Depth Depth 0 Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION R I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 teet.l Installation will serve: Residence it,' Commercial_ Other Number of living units: Number of bedrooms e Character of soil to a depth of 3 feet:,. Water table depth SEPTIC TANK. 0 Type/Mfg Capacity No. Compartments a PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line v\ LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well k Foundation Property Line ;I s r SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well r j Foundation Property Line DISPOSAL PONDS ❑ i f I hereby certify that f 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 iignature't6nifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not ,.or 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 vvich.thin permit is issued, l shall employ persona subject to workman's compensa- tion laws of Califor 'a." The ap i t must I for-all fequir6ld in ,ctions. Complete drawing on ver side. ' Ti : Signed ��Title:-\ Date: 4 � OR-DEPARTMENT USE ONLY PP Accepted byDate� ,_ �— C2ZA 2- location Acce e i t. 0. A- - `" Z Area A S • Pit or Grout Inspection by �! ' s Date Final Inspection by Date Additional Comments: I d Applicant - Return all copies to: San Joaquin County Public Health Services q Environmental Health Permit/Services 445 N San Joaquin, P O.Box 2009, Stkn, CA 95201 FEE AMOUNT DUE A OUNT REMITTED CK RECEIVED BY DATE PERMII'N0. INFO . EH 13.20(REV. /N S) ( �/ 1 X�/ 9 � ,^,/11,1911 -3 EH tI-ae �//`— ter Ih u I!