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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES b 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 2-94/V � � 4 9 (Complete in Triplicate) N �fE Application is hereby made.to San Joaquin County for a permit to construct and/or install the work helre3iniIdte"scrC 'ibed, This I application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regtilistly, oisSan Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's Name ZZ2 , J/4/5' AddressC� Phone /pQ-,90it11//9 Contractor Address Ln-w=FA-Ra License No. ` -✓�/ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C5 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR iK OTHER ❑ Monitoring Well E3 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS -- -- - - -- 1NTENOELI'USE F -TYPE'OFI+VELt PR'OBLENI #SEA`ICON'S fil7CTION'SPECiFiC4T10N5� F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing [I Domestic/Private Ci Gravel Pack 0 Tracy Type of Casing_ Specifications I•I Public CZ Other 171 Delta Depth of Grout Seal Type of Grout C� I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by `\'w Repair Work Done L] Type of Pump ,12/A H.P. _15 State Work DoneAQ)9_=J_7 F�� (� Well Destruction ❑ Well Diameter Sealing Material. i Depth Depth Filler Material A Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION l I INo septic system permitted if public sewer is t available within 200 feet.) Installation will serve: Residence Commercial— Other Number of living units: Number of bedrooms l s r^ Character of soil to a depth of 3 feet: + Water table depth SEPTIC TANK. v ❑ Type/Mfg -Capacity-_:.t ! I No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Lirie _. LEACHING LINE Cl No. & Length of lines Total-length/size - FILTER BED ❑ Distance to nearest: Wel; Foundation Property Line SEEPAGE PITS 11 Depth Size Number. SUMPS Ll Distance to nearest: Well Foundation Property Line 4:r _ DISPOSAL PONDS,_- ❑_ 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: "! certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such ner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: " 'y 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 Californ The applicant m all uired insAections. Complete drawing on reverse e k Signed X Title: �'+ Date: 1 FOR DEPARTMENT USE ONLY T Application Accepted by Date L46-12/ �y Area 2/ Z. Pit or Grout Inspection by Date Final Inspection by Date Z Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P box 2009, Stkn, CA 95201FEE ` INFO AMOUNT DUE AMOUNT REMITTED CK RE EIVED BY DATE PERMIT-NO. �. EH3 24• Vn S � ov 7 aIe EH i ` - I