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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 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. Thie application is made in ccepliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public �jHealth cSeervices. Job Address 16 s� / !AV_,d6g,4"A City 41;POAV Lot Size/Acreage 0405 Owner's Name R Al 4 GrClr7 Address Phone Contractor t4t1rMeAfAddress 0 LvCi w•1 //A License No. ytiLA Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ `j PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well U DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE W9LL OTHER WELL PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS FI Industrial O Open Bottom O Manteca Die. of Well Excavation Dia. of Well Casing f I Domestic/Private ❑ Gravel Pack 0 Tracy Type of Casing_.___ Specifications Il Public 1-1 Other fl Delta Depth of Grout Seal Type of Grout I I Irrigation __ Approx. Depth I I Eastern Surface Seal Installed by r Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Mattrial i Depth ` 1 Depth Tiller Material i Depth V TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other /`90 bi L.. Number of living units: _� Number of bedrooms Character of tori to a depth of 3 feet: 1 Arid K Water table depth ab s SEPTIC TANK a Type/Mfg A% CAQr Af G Capacity VA e 0, No. Compartments Z l PKG. TREATMENT PLT. ClMethod of Disposal ,,y�.. Distance to nearest: Well � Foundation '�-r Property Line /eel eel i LEACHING LINE Q1 No. 6 Length of lines 2 — V& _— Total length/size Ya FILTER BED O Distance to nearest: Well 100, Foundation A r Property Line �S SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 tha fdNowing: "I certify that in the performance of ttie work for which this permit is issued, I shall not employ any person in such manner as to become subject to workmen's compensation lawl 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 mut call for all required inspections. Complete drawing on reverse side. Signed X ; XZ Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by � ��..� Date — Area Ph or Grout Inspection by Date Final Inspection by ate%LlzgL Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquid, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED K RFfEIVED BY O E PERMIT NO. INFO ,/ FH 1179IIIEV.riser 1 1 ,aD // /p �J FH 1/-29 �./ / !/