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SAN. JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 � P 0 BOX 2009, STOCKTON, CA 95201 i PERMIT E%PIRES 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 wont 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 Service's. 2 y 211 : �0 `�'��_ Lot Size/Acreage � A GE Job Address City�— 4 Address M C Phone 81✓- Owner's Name Ar? p {� �/� �} et 1�p �Jt .) 1'y'�icense No. U� 19 Phone Contractor dress TYPE OF WELL/PUMP: NEW kWELL D WELL REPLACEMENT F DESTRUCTION C1 Out of service Well Monitoring Well C7 " PUMP INSTALLATION 12 SYSTEM REPAIR ❑ OTHER ❑ l q DISTANCE TO NEAREST: SEPTIC TANKA SEWER LINES DISPOSAL FLD. PROP. LINE ' FOUNDATIONr; AGRICULTURE WELL OTHER WELL PITS/SUMP INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �. Cf industrial C� Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing [.) Domestic/Private ❑ Gravel Pack ( n Tracy Type of Casing- VSpecifications Cl Public 1-1 Others t fl Delta Depth of Grout Seal Type of Grout j _.Approx. Depth I i Eastern Surface Seal Installed by t I Inp i0alion ;. Repair Work Done 0 Type of Pump � H,P. State Work Done Well Destruction 0 Well Diameter # Sealing Material & Depth Depth "r Filler Material 1pth 1 f TYPE OF SEPTIC WORK: NEW 1F.1S.T.ALLATION I I REPAIRlADDITION I DESTRUCTION I I iNo septic system permitted it public sewer is y $;� available within 200 feet.1 Installation will serve: R i enc@#q1;'�F� ommerclal Cher Number of living units: N.Iinsber of bed ms Character of soil to a depth of 3 feet: . Water table depth SEPTIC TANK. D Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ r- Method of Disposal Distance to nearest: Well Foundation Property Line X, LEACHING LINE No. & Length of lines t T tai lengtsize �. FILTER BED f:] Distance to nearest: Welt `- y`Foundation Property Line b f SEEPAGE PITS 11 Depth Size Number'�' � SUMPS CI Distance to nearest: Well Foundation i F Property Line DISPOSAL PONDS ❑ t " I hereby certify that I have prepared this application and that the work will be done+n accordance with San Joaquin county ordinances, state laws, and I rules and regulations of the San_JoaquinmCounty. f ' ?-4- ' 1 r 1 1 Homeowner 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 1 employ any person in such manner as to become bject to workman's compensation iaws,of California." Contractor's hiring or subcontracting signature certifies the following: "I certify that in the perfor ance of the work for permit-is-issued-, I-shall employ persons subject to workman's compensa tion taws of California." t The applicant must for all r inspec ns. Complete draw on reverse side. G Signed X � _ �"� Title: y""alb. '` Date: i FOR DEPARTMENT USE ONLY fiX + V Application Accepted by Date r � �,. Pit or Grout Inspection by Date Final Inspection b Date Additional Comments: —Applicant—"Return- 9:11 copse's to:—BFLn"Joaqurn-County Public'Healtki Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 IFEE NFO AMOUNT DUE ,AMO_UNT REmirr f CASH _ ,aRECEIVED BY DATE PERMIT NO. EN 13.24{REV-1/x 91 EH 14.26 i