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- ] SAN JL ,JUIN'-COUNTY PUBLIC HEALTH S- '7ICES IRONMENTAL HEALTH DIVISIO 445 N SAN.'jOAQUIN, PHONE (209)468=3420 P O BO%'"2009, STOCKTON, CA 95201 PERMIT EgPI13ES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County ifor' spertait 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. f i k Job Address /4-A+Z i J'-G ta..'AY C.= ;yE, L CiryLot Size/Acreage 1 t 4 JC zgCJC1 , Sgry c^alrrAcr MZ: At_1i I Owner's Name A e{bt•t C Gi�M�1=rZY Ad"dress- O X r t 3`7 ST C t��N C i4 9Y�1 Phone; (ofr— fc-ACs .Z:52at'S:Lam. R—.'Lx $ C7,C1�i Contractor �► i=C TiZyM Address CA 45;kG' License No5f Z&� --Phone TYPE OF WELL/PUMP: NEW WELL 1 "'�WELL REPLACEMENT n DESTRUCTION 5 Out of Service Well C) PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well pISTANCE TO NEAREST: SEPTIC TANK �y-_ 5EW.EA !LINES A- DISPOSAL FLD.7 O f PROP. LINE O `� f ��Qf PITS/SUMPS �A- FOUNDATION 7/ AGRICULTURE WELL s� OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS to 0 Industrial ❑ Open Bottom 0 Manteca Die. of Well Excavation Dia. of Well Casing Ai ,`Domestic/Private ❑ Grave) Pack7 ❑ Tracy Type of Casing_ PVC— Specifications Scar 40 — N0wrft IQJV-Z (s f'I Public �Other�+OnnTr]taA(,rCv1 'Delta ° Depth of Grout Seal sus -- Type of Grout I I lrrigation —Approx. Depth Qasiem. Surface Seal Installed by Repair Work Done L] Type of Pump HP. = State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Filler Material & Depth Depth f'..,_,-,.,k TYPE OF SEPTIC WORK: NEW INSTALLATION i I I REPAIR/ADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet.) I; Installation will serve: 'Residence— Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet:g "� '� ,e h SEPTIC TANK. ❑ Type/Mf Capacity ft nta PKG. TREATMENT PLT.❑ Distance to nearest: Well :Foundation Pro¢dhV t no,.., 10AQ VIC LEACHING LINE ❑ No. &Length of lines Total � " FILTER BED Cl Distance to nearest: well-, Foundation �NAR�Vem Line r SEEPAGE PITS f i Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line ' DISPOSAL. PONDS '❑ I hereby cenily 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 dik;mari s compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I comity that in.the performance of the work°;fat which this permit is issued,1 shall employ persons subject to workman's compensa- tion laws if California." ; .�47--`�if--Z The applicant ai call fir all regyj inspeions. lato drawing on reverse side. Signed 4,Title. Data: t - FOR:DEPARTMENT USE ONLY Application Accepted by .f Dare -C619 Z Area Pit or Grout Inspection by fla�e Final Inspection by Date Additional Comments: - r Applicant - Return all copies to: San Joagtif; , a'iCounty Public Health Services ' tiavif6wfiental Health Permit/Services 445 N Sari ';loaqufn, P 0 Sox 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITtt& CK H RECEIVED ay DATE PERMIT'NO. INFO (� -y . EH13-21CAEV.ri�s� t �1� -7q } q� f ~d .Z t' i EH 71.26 [[[C!!!! 00— ..__. 41