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i SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made Lo San Joaquin County for a permit to construct and/or install the work herein described. This application is made in com;iliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 1.3-z :.sr",3 �� /o�Si/�'SaAr gds City 3�.e�Lv A' Lot Size/Acreage Owner's Name O �X%A Address 3 3'VJ Sd• V-lve At C,,iv Phone �Y. "Contractorof Address O4d7, E�� 9 dF License No.�y�y��l__Phone TYPE OF WELL/PUMP: �� NEW WELL ❑ WELL REPLACEMENLT 171 DESTRUCTION C7 Out of Service well 0 PUM ,,,,INSTALLATION 0 SYSTEM REPAIR L) OTHER 0. Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE -FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C} industrial 0 Open Bottom•-- C'Manteca�b•= Dia. of Well Excavation. Dia..of:,Well-Casing C:3 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public Cl Ot4r n Delta Depth of Grout Seal _ Type of Grout I i Irrigation — Approx. Depth I I Eastern Surface Seal Inslalled by Repair Work Done U Type 4f Pump H.P. State Work Done Weil Destruction D )Well Diameter Sealing Material & Depth DeptO Filler Material 6 Depth TYPE OF SEPTIC WORK: NEWINSTALLATION)1 REPAIR/ADDITION I I OESTRUCTION.1,1 INo septic system permitted if public sewer is � "available within 200 feet.) Installation will serve: Residence_ Commercial— Other YISAII Number of living units: j Number.ofFbedrooms Character of soil to'a depth of feet: /Y/0 Water table depth SEPTIC TANK 123 Type/Mfg ,ire_CA9 St -Pif L Capacity La00 No. Compartments PKG. TREATMENT PLT. C7 I , Method of Disposal . Distance to nearest: Well Q Foundation Property Line _/ `rtGt LEACHING LINE No! 8 Length of lines' /00--14, ,9�fTls Total length/size p' FILTER BED 0 Diitance to nearest:/WellL Foundation %d' Property Line SEEPAGE PITS 11 Depth 6 v Size 'X "'"�Wimber=�="" - r SUMPS jf Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 IN. I 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 shell 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 certifies the following: "I 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 mus call for all required inspections. Complete drawing on raver side. 11 i t Signed Title: Date: FOR DEPARTMENT USE ONLY :I lication Accepted by A-AW Date D Area T'liAd Grout Inspection by Date eI lns action by Date onai Comments:pplicant - Return a1PMco les to: San Joaquin County Public Health Services i Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 i FEE AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'N0. INFO f . Em 13-24 111EV.iinss !/ /] %�J%/J7� EH 14.26 :i f J I�