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SAN &UIN COUNTY PUBLIC HEALTH /ICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 - ' PA ','�'MCid» P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AUG 0 3 1Cl,93 (Complete in Triplicate) SAN jQAQUINiiG.;NTY Application is hereby made,to Sm Joaquin County fora permit to construct and/or install�Q�J9 UB a Jf rt Tdl'es31•-f�`�{f:cSfhis application is made in compllmce with San Joaquin Couny Ordinance No. 549 and 1862 and tltE Hti1�15' 'Aegt�tiohalb0$;�q Joaquin County . blit Health Services. c Job Address L I 1• City :T Lot Size/Acreage 2alUe ND r � �r G Pit Z0- 'A -• i (', J.z /� � Phon� Owner's Name c — _ � ddress —6""' �� i Contractor T Address C�.L.�rm man 4,- 2SZ, Licensef-Service well `-/ Phon TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ,^, DESTRUCTION El Monitoring Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER C ❑ 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 SPECIFICATIONSNo ruv J ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /i�• S' Dia. of Well Casing 1711, ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ PVtr Specifications I'I Public llTOther n Delta Depth of Grout Seal //, Type of Grou• z10 -f sn.d ljl- Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done -Well Destruction ❑ Well Diameter Sealing Material i Depth (Ai rM� r-? I /rsn47�111� Depth g} Filler Material i Depth rtl " ?�� 1•�-�: y TYPE OF SEPTI WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I septic withsystem per titled J public sewer is 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. i Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Line SEEPAGE PITS it Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line 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: '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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compensa. tion laws of California." The applicant must call for all requirednspections. Complet drawing on reverse side._ nn :f �� Title: Date: Z Signed % � t I 'YP X11 L �. — ` FOR DEPARTMENT USE ONLY / f,7�p) Application Accepted by v, �q✓�i t�" Date nS -3 Area �7 Pit or Grout Inspection by � r' Date �3 /✓ Final Inspection by S Additional Comments: IlC.� IAAO1 "D n /`� Applicant - Return all copies to: San Joaquin County Public Health Services o' /`� 7� Environmental Health Permit/Services (•,'(� J 1 445 N San Joaquin, P O Box 2009, Stk., CA 95201 At FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. INFO p 31 /- • EH 133x '�/ V�� EH 14-A