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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 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 ,I (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 , J`oaquin County Public Health Services. 12-7 i (q ' Iv iIvA ,i� C.C-7"Xr=�y Llv, Citys C/ U� Lot Size/Acreage 1/•20 Job Address �� SAru �e�pc,�sN C^a�.�-oC7 Mid At VrG1 k Lr Owner's Name C ,7wi t c CSM p-n= 1 Address d +t 3'T S��fG'a``� G�� Phone � - Contractor p G ryM Address k+ylvf e-A 95,?A!� —License NoSf TYPE OF WELL/PUMP: NEW WELLY ;;�� WELL REPLACEMENT E'] DESTRUCTION Cl out of Service Well ❑ PUMP INSTALLATION C1 SYSTEM R PAIR ❑ OTHER p MonitoringWellX, DISTANCE TO NEAREST: SEPTIC TANK -�`7 — SEWER LINES A-1 •.._.L 0 DISPOSAL FLD PROP. LINE '>4 0� 0) F=OUNDATION. }�a AGRICULTURE WELL ?9Q'OTHER WELL r PITS/SUMPS 1._ — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS rr rri I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing µ lit Domestic/Private ❑ Gravel Pack I ❑ Tracy Type of Casing_ PtfC- Specifications :,_=-.- . ['I Public v�r�o tics 'KOtherromTOXIA6 17-1 Delta Depth of Grout Seal 5� Type of Grout I i Irrigation Approx. Depth astern Surface Seal Installed by sf XC - Repair Work Done U Type of Pump'] H.P. State Work Done Well Destruction ❑ Well Diameter ' Sealing Material & Depth Depth f Filler Material &.Depth b TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other . . I Number of living units: Number of bedrooms 0e,p�� h Character of soil to a depth of 3 feet: ��} SEPTIC TANK ❑ Type/Mfg Capacity I�WYfi' nts PKG. TREATMENT PLT. ❑ i Ithpd9%f sal Distance to nearest: Well Foundation Proofty�!�tv Y 10 x LEACHING LINE 0 No. & Length of lines Total � r # FILTER BED n Distance to nearest: Well Foundation _ FLS arty Line �I SEEPAGE PITS 11 Depthf Sue Number SUMPS LI Distance to nearest: Well Foundation Property Line "DISPOSAL*ONDS l ❑ 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 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 workman's compensation laws of California." Contractor's hiring or sub-contracting signature�� certifies the fotlowing: 1 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." A7-��rte The applicant st call for all req r ins aVfiGnS. Qprplets drawing on reverse side. p -719 Signed X_ --�� t Title: CA- 1'"- '>'o 21 Date: f FOR DEPARTMENT USE ONLY Application Accepted by Date 31 Area G'e`t' Pit or Grout Inspection by ( Date Final Inspection by..: ka&� Date ABditional 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 I FEE � INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY PATE /y+PERMIT NO. Z4(REV.11MSS U F� �' 4 {