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M � SAN.1JOAQUIN COUNTY PUBLIC HEALTH SERVICES i f t _ I ENVIRONMENTAL HEALTH DIVISION i 445 N SAN JOAQUIN, PHONE {209}46$-3420 y fP O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) iin described. Application is hereby made to San Jroa�uisnancounty uin Co r a ty ordinancenNo. 549and/or 1862install and thethe Rules andeRegulations of SanThis application is madecompliance Joaquin County Public Heal Services t O �. a r� C y�S S 3 � !J� City Size/Acreage Job Address Name IJ��6� ��r f�Y Address _21) `(Phone Owner's Na ) � � r� k 1 gi �1 Phone J• s / � •Address - - it�nse No Contsactor� - DESTRUCTION out of Service well ❑ -�v---- — WELL REPLA MEiT o Well NEW WELL ❑ OTHER ❑ Monitoring W TYPE OF WELL/PUMP' , ,,_., - " '" PUMP-INSTALLATION, SYSTEM REPAIR ❑ _ _ _ t F OkST .,,,,c,,,.E. ANCE TONEAREST: SEPTTICIC TANK SEWER LINES D DISPOSAL FLID Tr_ — - FOUNDATIONAGRICULTURE WELL THEIR WELL WELL— PITS/Su MPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIGATEO '1 l / ,� _ Dia. of Well Casing C] Industrial ❑ Open Bottoms. - Manteca Dia. of Well Exc"j"'o•^•—r: D LSpecificationsType of Casing_ Specifications I ( Domestic/Private Gravel Pack ❑ Tracy .. .p._. Type of Grou i'l Public " f.7 Other Cl belts Depth of Grout Seal/, ' ' '" " ""i°r '. . Surface Sesi Installed by I I Irri anon GApprdx. Deptht I Eastern g ti _ State Work Done Repair Work pone U Type of Pump H,P. IxJB�� i /►, .,.- Sealing-Material-& Depth Ala— Wall Destruction Well Diameter IN� a�-- Biller Material 8 Depth Depth - - No septic system TYPE OF SEPTIC WORK: NEW`INSTALLATION 1.) REPAIR/ADDITION I I t)ESTRUCTION I l available within 200 feet111ed rf public sewer{is + i Installation will serve: Residence Commercial— Other j Number of bedrooms •, Number of living units: �. j Water table depth ' 'Character of soil to a depth of 3 feet: Capacity--- No. Compartments SEPTIC TANK. ❑ TypelMfg Method of Disposal PKG. TREATMENT PLT. 1•-�- �` -.V �� ' Property Line m Distance to nearest: Well - .Foundation Total length/size t!EACH4NG LINE 0 No. & Length of lines J . } ' Foundation Property Line y�FILTER BED ❑ Distance to nearest: Well _ _ Number SEERAGE,PITS 11 Depth Size Property Line SUMPS 'Ll Distance toynearest: Well - Foundation 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 laws, and rules and regulations of the San Joaquin County i;.'., 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 personrn 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:" '` f� The applica/� st oal for all req d ins etions. Complete drawing on reverseq Side r Date: `� y �� / Signed K �ir Title: y /. Q FOR EPARTMENT USE ONLY Data 1 L� a Application Accepted by I Pit o Grout I spsction b Date "� Final Inspection Date k Additional Comments: F Applicant - Return all copies to: . San Joaquin County"Public Health Services, -'- k r•T—Envi-ronment`al Health Permit/Services L __ tom'` 495-N-SangJoaquin-,.P�O;�ox 2009, ,C StknA-*95201—a-- f� ICK FEE A O NT DUI: i. AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT NOS INF . ` EH 13.24iREV.1in5i / Z �a/� EH 11.2E -f Z_1i� -