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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOR 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in 'Triplicate) Application in 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. \ Job Address 's City Fr�neh CL• Qot Size/Acreage 1�� Owner's Name �VV , �L��/ra Addrass _O_99 ---�Od�lX.lJ_ ---------.__--- Phone / ' Contractor dress 1 _ License No4EI� Phone TYPE OF WELL/PUMP: NEW WttL ❑ WELL REPLACEMENT Fl DESTRUCTION (l Out of service Well In PUMP INSTALLATION O SYSTEM REPAIR Cl OTHER F) Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ._ DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r [l Industrial LJ Open Bottom n Manteca Dia. of Well Excavation _ Dia. of WAIT Casing f 1 Domestic/Private Ll Gravel Pack [l Tracy Type of Casing Specifications I'I Public [ I Other [I Delta Depth of Grout Seal Type of Grout I I Irrigation ___ Approx. Depth I I Eastern Surface Seal Installed by rn Repair Work Done C.7 Type of Pump H P. _ _ State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material 3 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION4� REPAIR/ADDITION I I DESTRUCTION I I (No septic sysilbrA permitted it public sewer is available within 200 feet.) Installation will serve: Residence -A_ Commercial_ Other 11 Number of living units: _�_ Number of bedrooms - 3 1 Character of will to a depth of 3 feet: Water table depth C.0_ SEPTIC TANK ❑ Type/Mfg eVC1_AS UC1 Ccapacity�l/ 0_ No. Compartments PKG. TREATMENT PLT. Cl L Method of Disposal Distance to nearest: Well Foundation .� Property Lind 0 LEACHING LINE Ll N�o.��e/p thtyofelin� Total length/size_ _ FILTER BED [_V Di3tanc3td ribarefst:�� ell Foundation Property Line _ r SEEPAGE PITS 11 Depth Size _— _ Number _ SUMPS [.1 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state law;, 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 shell 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 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." The applicant must call for all requi ed ' ctions. Complete drawing on reverse side. Q, Signed Title: 6A_e� _ Date: V '-- R EPARTMENT USE ONLY _ C., Application Accepted by � 'l�►MTiC7o...o Da�by _ e �_ � At Pit or Grout Inspection by Date Final Inspection eAdditionelComments: I , James Hancock, Owner of 8899 Endow d verify that sep is ystem was Installed as sriown on perms cv � , Applicant - Return all copies to: San Joaquin County Public Health Service, - (1 Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED R CEIVED BY D E PERMIT NO. INFO SH> EH 1324MEv rin51�A' Lf tl?J00 I� =(.�— , �- / �f EH 1126 1 v ___.