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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION f 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 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 loo. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. r Job Address 4 330 dE+ Quly e �1 /� � /J. ._ City ! +e791 Lot Size/Acreage /1 AcIr-1- Owner'a Name R4 e �r2/'�� Address Sate 9s Jove - Phone I /� [s 9i z License No.P.9.5 ' Phone 92 �+ Conlraclor �7' /t'i *►`D Addres + TYPE Of WELL/-PUMP: ;% ---.NEIN WELL�i ,g �A --WEL=L-REPT=ACEMENT4.C-] ;;,i-DESTRUCTION ❑-Out of Service Well ❑ C - : y- rrPUMP:INSTALLATION. ....,...,r..KSYSTEM-REPAIR ❑ OTHER ❑ Monitoring Well. L� DISTANCE TO NEAREST:. r'� -SEPTIC TANK Lh - :SEWER LINES .S�l� _- DISPOSAL -FLD.� PROP..LINE FOUNDATION + 'AGRICULTURE WELL OTHER WELL&D` 4 PITS/SUMPS c,..^ i INTENDED USE TYPE OF�WELL PROBLEM AREA CONSTRUCTION SPECIFICATIO E LI Industrial ❑ Open,Bottom Manteca Dia. of Well Excay tion. �� Dia. of.Well Casin t )<Domestic/Private Gravel Pack ❑ Tracy. Type of Casing�yc- /C�+ Specifications 1 1 Irrigation fox. Det I 1 Eastern triface Seal Installed b �`0- 12Cti'1 Public 1-1 0th r f ClDelta Depth of Grout SealYpg PY e of Grout - k Repair Work Done LJ Type of Pump k. UT H.P. State Work Done_ Well Destruction' ❑ Well Diameter - = =.Seali.ngrl�lnterial & Depth %`- t De th'V � Filler Material & Depth TYPE OF SEPTIC WORK:, NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet,) f Installation will serve: Residence_ Commercial_ Other t * c Number of living units: N umber of bedrooms *� x ' Character of soil to a depth of 3 feet: ti t, '' Water table depth SEPTIC TANK O Type/Mfg F Capacity No. Compartments i PKG. TREATMENT PLT. ❑ a Method.,of Disposal Distance to nearest: Well- Foundation Property Line k� y h LEACHING LINE ❑ No. & Length of lines Total length/size 4 FILTER BED ❑ Distance to nearest:_Well., -.: Foundations•-=-=-- Properly Line �. P V-� SEEPAGE PITS 11 Depth Size Number t `f SUMPS LI Distance to nearest: Well Foundation - -=-Pro k . party-Eine DISPOSAL PONDS ❑ ` F 1 hereby certify that 1 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 empioy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring of sub-contracting signature certifies the following: 1 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 mpi call f r all require inspectio s. Complete drawing on reverse ,si�L 9 Signed X�.11� � � Title: [ {'� Date: 'y _T •' {^` FOR DEPARTMENT USE ONLY i Application Accepted by ` ` t Date a Pito J rouC' apectian b DatFinal Inspection by_ pate f ` '' 7 �, ti,• p r� 1 ` ' ' Addition Com ts: -//OO ��jj G,� ¢ a - + A C t - turn-Zllf- ' �s�o n�COu y:P�6tfii'c"HeaIth'Seirvites Environmental Health Permit/Services 445 P San Joaquin, P O Box 2009, Stkn, CA 95201 rFEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DAY ERMIT'NO. r EH 24 EH t{•20 1REV.i/ 51 �i 1`Ii e {/