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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 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) i Application is hereby made to San Joaquin County for a permit to construct and/or install the Work herein described. This in County Ordinance No. 549 and 1862 and the Rules and Regulations of San application is made in compliance with San Joaqu Joaquin County Public Health Services. Job Address 8457 71Lea,6uue AUL City Stkn Lot size/Acreage ' ,�ccany /3z.i3coe Address game Phone 931-0964 Owner's Name Contractor C-eaitk Ueil, Iris Address 2024 E. Chan�tcA Gla License NO 7 15 60 Phone 4 6 2_-__Z_6_L_ of Service Well [3TYPE OF WELL/PUMP: /NEW WELL ❑ WELL REPLACEMENTXCa DESTRUCTION :t Monitoring Well C1 PUMP INSTALLATIO�dffX SYSTEM REPAIR ❑ OTHER 1:1 r 7 C)�' SEWER LINES DISPOSAL FLD. PROP. LINE _tL DISTANCE TO NEAREST: SEPTIC TANK �, FOUNDATION AGRICULTURE WELL OTHER WELL---- PITSlSUMPS00 i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a Ll Industrial © Open Bottom C1 Manteca Die. of Well Excavation 12 Dia. of Well Casing Type of Casing Specifications p fir)!) r Domestic/Private &1 Gravel Pack C1 Tracy YP g- i'1 Public f_1 Other ❑ Delta depth of Grout Seal 100' Type of Grout stn Ck— I I Irrigation _Approx. Depth �7I i Eastern Surface Sedi Installed by — L1 k H.P. 1 1 ,_State Work Done n r,o Repair Work Done U Type of Pump J Sealing Material & Depth Well Destruction EI Well Diameter 6 n Depth r Filler Material & Depth n iii It TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIRJADDITION ( 1 DESTRUCTION I I INo septic system permitted i{ public sower is available within 200 feet.) Installation will serve: Residence— Commercial— Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity m No. Compartents PKG. TREATMENT PLT.C) Method of Disposal Distance to nearest: Well Foundation Property Line o ' LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED 11 Distance to nearest: Well Foundation Property Line Ik k SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 0 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 shall 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 applican - call or a . q ' i i omplete drawing on reverse side. Signed Title: VP- Cia.,k 1),e.-it1),ef-it Inc. Date: 30la-61 9 2 . FOR DEPARTI FNT USE ONLY Application Accepted by Date Area ' Date 'f incl Inspection by - Date g / Pit or re t Inspection by ` Or l Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 I`E'EE �;AMOUNT DUE AMOUNT'REMITTED C RECEIVED BY DATE moo• W F4 Err 53.24 IREV,i i a 51 n / / EH 14.2e 7� i W iD /