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SAN (__�QUIN COUNTY PUBLIC HEALTH . ';VICES '-'ENVIRONMENTAL HEALTH DIVISIOW- 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 , PERMIT EXPIRES I YEAR FROM DATE ISSUED L (Complete in Triplicate) Application Is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services.``` �+ ^ ,t Job Address _ � L '�1 City S� A �Lot Size/Acreage !� C Owner's Name Address `'��/L�' Phone Contractor r 61!7"1 _L.4ZOS3 3 Addres/3 `_ L __ _ License No3_.32F-f' Phone37~��"r TYPE OF WELL/PUMP; NSW WELL WELL REPLACEMENT n DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATIO SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK /Ja SEWER LINES DISPOSAL FLD. " PROP. LINE o`er FOUNDATION' AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavalin.__ fh_ Dia. of Well Casing -4eDomestic/Private Gravel Pack ❑ Tracy Type of Casing_ Specifications /C^c!lo I'i Public 1-1 Other (l Detta Depth of Grow Sea! l d� Type of Grout GS/1t_CH____ I I Irrigation `�-5`1 Approx. Depth I I Eastern Surface Seal Instailed by 041 Repair Work Done U Type of Pump SZ►1-� H.P. Z State Work Dana Well Destruction ❑ Well Diameter Sealing )Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION i I DESTRUCTION I 1 INo septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial— Other �1 Number of living units: Number of bedrooms t Character of soil to a depth of 3 feet: Water table-depth SEPTIC TANK ❑ Type/Mfg,' Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 f16. & Length of lines Total length/size FILTER BED 0 "Distance to nearest:. Well Foundation Property Line SEEPAGE PITS I I Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I 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'JF6aquin 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 canify that in the performance of the work for which this permit is issued, 1 shall employ persons�ubject to workman's compensa- tion laws of California." The applicant must 01 for§Wrequired inspections. Complete drawing on•reverse side. Signed Title: ! Date: F R DEPARTMENT USE ONLY 1 1 f �' Application Accepted by Data �L ��AA/�J Area C)r ''��.1 4 Pit out ns ction by r Date S^2 Final inspection by 11 Dat. 6 9 Additions omments: 1 Applicant - Return all„ opies to: San Joaquin County P b11c Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 EE CK d E,15 , MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI NO. 04, �1 EH• EM 13-74 IREV.1/NSi010 J,�j 7 ,L` 1 �`3_O$7