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n Al'111-i1L:A'1'l Uff PUN, ltklutll SAN JC 'TIN COUNTY PUBLIC HEALTH S' 'ICES O '-!VIRONMENTAL HEALTH DIVISIOr— 445 SAN JOAQUIN, PHONE (209)46 420 P O BOX 2009, STOCKTON, CA 95201 pERMIT EXPIRES 1 YEAR FROM DATE MOM (Complete in Triplicate) Application is hereby application is aside ncooeWllance vith San Jaquinfor county Ordln"cermit to nNo. 549and/or 1862 and thethe Rules andherein Reralatlons of SanThis Joaquin County Public Health Services. /��a,�, sae of a �nC//✓�h✓s/ lam City la�.ticJ " Cot Size/Acreage Job Address -f Jj �pk40",QOsi^.� V�� Address 1103 / 7�G QC C�iY1� Pho Owner's Nana _,!go /_n��J CA-No. nd I � �(oq Gena/ni L✓) W LicensevN•o. 9�r239y Pha} O -6G 3 Contracts rets TYPETYPE OFWELD NEW WELL WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ C1SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well PUMP INSTALLATION DISTANCE TO NEAREST: SEPTIC TANK _T_ SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 1120 AGRICULTURE WELL ( aMt OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin C, Industrial PV L Specifications CI Domestic/Private ravel Pack ❑ Tracy Type of Casing_ -y _ � 1'1 Public 17 Other p(pelta Depth of Grout Seal S Type of Grout I"'+t I I Irrigation _Approx. Depth I I Eastern Surface Seal Inst IIA b, I Repair Work Done ❑ Type or Pump H.P. State Work Done _ Sealing Material a Depth Well Destruction ❑ Wait Diameter Tiller Material L Depth Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I IvsilabO "Pic sYs m perleeched if public "wet is Installation will serve: Residence_ Commercial_ Other Number of living units: - Number of bedrooms Water table depth Charte or sto a depth of 3 Mt: sooil f Disposal nts SEPTIC TANK ❑ Type/Mfg Cap+citY Co No. PKG. TREATMENT PLT. ❑ MetMethodoof Dispossaa l DMance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I height, certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rues and ragu4tions of the San Joaquin County Home owner a licensed agents signature certifies the following: "I certify that In the performance of the work for which this permit is issued. I snail not employ any parson in such manrar as to become subject to workman's compensation lawn of California."Contractor's hiring or subcontracting signstua terrifies the following: "I unity that in the performance of the work for which this permit is issued, I shall employ persona subject to workman's compenss tion lawn of California." The applicant at R for all required spepti a. C mplets drawing on raver" side.� - P / Signed % Title: %U ^"' r , DeteC FOR DEPARTMENT USE ONLY DateA/ el-T Area Application Accepted by Ph or Grout Inspection by � /� tD/a�is ///�73,y Frinaall I—nspection by_. .'v/^ ,`/�_`` Deal �l4 �3 E•A • ka(, � Y'LU�u'r/"7fr V. e Additional Comments: -V-�-- V Applicant - Return all copies to: San Joaquin County Public Neat/ lth Services �z,OO Environmental Health Permit/Services / 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 0t/ DATE PERMIT NO. INFO �7 q / y tH 14-M