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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) . . Application is hereby made to San Joaquin County for & permit to construct and/or iniatitL1 the vcirk application is made in comPliance vith San Joaquin County Ordinance No. 54 and 1862 and the Rules Joaquin County Public Health Servicesl 1F (2k) Job Address -1--4 6 00 4/ 11( AA/C19 City 191 Lot Size/Ac Owner's Name Ira be-Ari7 Address TYPE OF WELL/PUMP: NEW WELL ,/i4 WELL REPLACEMENT E Contractor / riq igit-'' rr Address /1 /7a.)' 11 j' DISTANCE TO NEAREST: SEPTIC TANK --.0.^ SEWER LINES DISPOSAL PLO. PUMP INSTALLATION -1‹ SYSTEM REPAIR C FOUNDATION AGRICULTURE WELL OTHER WELL DESTRUCTION Out of Service Well OTHER C t4onitoring Well PROP. LINE PITS/SUMPS TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 2CO feet.1 Installation will serve: Residence _ Commercial _ Other Number of living units' _ Number of bedrooms Character of soil to a depth of 3 feet: 7 --, --. , .„....r- Water table chtpth SEPTIC TANK: : 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. 0 Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well Foundation property Line I I Depth Size Number LI Distance to nearest: Well Foundation Property Line DISPOSL (hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin ocfunty 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 workmen's compensation laws of California." Contractor's tiring 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 taws of California." The applicant must7tr iii required inspections. Complete drawing on reverse side. _4 Signed X Title: Application Accepted by - Pit or(9Y Inspection by Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 herein described. This and Regulations of San eage &-Y41.46 Phone License No.3773r I Phonelj v-921) 0 0 INTENDED USE Cl Industrisi Domestic/Private 1'1 Public I i Irrigation Repair Work Done Wet/ Destruction TYPE OF WELL 0 Open Bottom 'Gravel Pack I:1 Other '1/4_1511P— Approx, Depth O Type of Pump 0 Well Diameter Depth PROBLEM AREA CONSTRUCTION SPECIFICATIONS 0 Manteca Die. of Well ,Excavation / I-- Dia. of Well Casinst P D Tracy Type of Casing__ P 40<- Spe :ifications I-1 Delta Depth ol Grout Seal loa Typt of Grout C C-#7 41-r I i Eastern Suace Seal Installed by C 0/'4,--r-r."..c-701%. H. P. i - State Work Done 03,- S7.4ely Sealing Material & Depth Filler Material & Depth SEEPAGE PITS SUMPS A PONDS 0 Date . ,atz 7 -2Ai Date -17 Are71 1/-7: FOR DEPARTMENT USE ONLY 743 Final Inspection by7:1-e2-19/77/2-1-r--re-Aate-7--- ?isTh-rit,/ 644v /VA 'pi, PA409 . Ei 1114 MEV. 1 1 14-28 FEE INFO P1%) AMOUNT DUE AmOuNT REMITTED CK i - RECEIVED BY CASH DATE PERMIT NO. (IA) I 3 c/ -------1-19 ° / 3 ti. ---- .a/S é .K 1