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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />445 N SAN JOAQUIN, PHONE (209)468-3420 <br />P 0 BOX 2009, STOCKTON, CA 95201 <br />PERMIT EgPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in.Triplicate) <br />Application is hereby made to San Joaquin County for a permit to construct and/or install the Work herein described. This <br />application is made in compliance with San Joaquin County Ordinance no. 5k9 and 1862 and the Rules and Regulations of San <br />Joaquin County Public Health Services. <br />7 y Lot Size/Acreage f L <br />City <br />Job Address <br />I �7- <br />'A <br />Address I ! !/ Phone <br />Owner's Name `�'� Al? �� Cl <br />Address `fWAk <br />icense No, 7 qD/8 Phone <br />Contractor DESTRUCTION Ci <br />out, of Service Well ❑ <br />TYPE OF WELL/PUMP: NEW WELL t❑ WELL REPL•ACEMENI Cl Monitoring Well <br />t yet 531'r ' �,iSY$TEN1`REPAIR 0 OTHER 0 <br />PUMP INSTALLATION"XI. ;• <br />SEWER LINES _ DISPQ'SAL FLD. PROP. LINE <br />DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br />FOUNDATION AGRICULTURE WELL OTHER WELL <br />.--Y tINTENDED-USE-=�--�TYPE-OF-WELL-- PROBLfMAREA-�CONSfi-RUCF-ION-SPECIFIC-ATIONS <br />f Well Excavation pia. of Well Casing <br />i 0 Industrial 0 Open Bottom 0 Manteca Dia. o <br />Type of Casing Specifications i <br />FI Domestic/ Private ❑ Gravel Pack L7 Tracy Type of Graut \ <br />(1 Other Cl Delta Depth of Grout Seal _ f <br />y ('1 Public Surface Seal Installed by <br />I I I lrrigalion �.Approx. <br />H.P.h l I Eastern,.,F3L State Work Dons N <br />r <br />Repair Work Dane U Typo of Pump 1, Sealing Material & Depth t <br />Well Destruction D Well Diameter Filler Material & Depth \y <br />i Depth <br />.TYPE OF.SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION i I arviiiable'w thin 200 feet.Isystem ed if public sewer is <br />initaliation will serve: Residence — Commercial I OtherTi <br />ps @ i <br />Number of living units: Number of bedroomst ��F�,��7e� <br />Character of soil to a depth of 3 feet: l✓Tmil" - <br />i-; t Capacity— <br />C <br />SEPTIC TANK0 Type/Mfg o of�t Drt <br />i 1 <br />PKG. TREATMENT PLT. Cl !Ilt; GO'U �Ty <br />Distance to nearest: Well Foundation Pr�(Y1��- �--=-- + <br />PLISLI,Ci' 14F=F7VICEa <br />r .j••' :.'..i .r Tota�F'1�lrr <br />L;EACHING LINE ❑ Na:`& Length of lines i t <br />FILTER BED n Distance to nearest: Well Foundation Property Line <br />'`^++ Number , <br />SEEPAGE PITS `. 1 1 Depth Size <br />SUMPS 11 Distance to nearest: Well • + •I#_Foundation Property Line y I <br />I <br />'DISPOSAL PONDS D _-�- <br />I hereby certify that I have prepared this application and -that the work will be done in accordance with San Joaquin county_o_rdinances, state laws, and <br />rules and regulations of the San Joaquin County <br />-Home owner or licensed agent's iignature certifies the folio +Iving; "I certify that in the performance of the work for which this permit is issued, l shall not <br />employ any person in such manner as tp become subject .10 workman's compensation lav of Caiifornia." Contractor's hiring or subcontracting signature <br />certifies the following: "I comity that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br />tion laws of C MS.— <br />The applic t St c r r Auired inspecti s. Complete drawing on re'erse1sida <br />I� 1�s �>�h _ Date: <br />l3 <br />Si ned Title: 4 z , <br />1 OR ARTM USE ONLY , t s <br />rte' i <br />',Date 1 res <br />Application Accepted by i + <br />I i y..__ <br />'""'� �'' Date Final inspection by - - oata� <br />Pit or Grout -Inspection by t t <br />l Additional Comments: -.. <br />t!Applicant - Return all copies to: San 3ekquin'County Public Health"Services <br />i Environmental Health Permit/Services <br />445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br />f <br />k FEE AMOUNT t?tJE AMOUNT REMITTED raFg! <br />E iJY DATE PERMIT"IVO. <br />IN <br />. EH 191 IiEV. `� <br />EH 71;6 <br />p <br />