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ce JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' - tl ENVIRONNENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 p O BOX 2009, STOCKTON, CA 95201 0i - . pEjWIT ggpIRES 1 YEAR FROM DATE ISSUID (COmplete in Triplicate) -work~�-r, and 1862 and the Rules and Regulations application is made in compliance with San Joaquin County Ordinance`Ifoof San Application ie hereby made to San Joaquin County for a permit to conetruet and/or inetal.l the herein described. This . 5 9 Joaquin County Public Health Services. / Lot Size/Acreage`— — -7 3 i�l U City L Job Address (/ LL �� I V f^ Phone C e- Address Owner's Name ' icense No. t 3 Phone , 4f ft Address t of Service Well [1 Conlraetor�- e WELL REPLAGEMENT Cl DESTRUCTION ❑ NEW WELL ❑ OTHER p Monitoring Well TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ PUMP INSTALLATION ❑ _ pISP_OSALLD -�P-flflP_._.Llfl.E�,�= DIST)4NCE TO'NE:AflEST:�-SEPT�IG TANK-SEPTICSEWER-LINES _ PITS/SUMPS �1 FOUNDATION �— AGRICULTURE WELL �._� OTHEfl WELL�� INTENDED USE TYPE OF'WELL PROBL� EM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing ❑ Open Bottom 0 Manteca Dia. of Well Excavation Specifications C� Industrial 0 Tracy Type of Casing_ i fa DomesticlPrivate Gl Gravel Pack Type of Grout I I'i Public la Other n Delta Depth of Grout Seal j 1 Surface Saul installed by I I I Irrigation —Approx. Depth 'I I Eastern to Work O ne Repair Work Done L3 Type of Pump lf H.P.amI Sealing Material & Depth Well Diammbt s�,� Well Destruction Filler Material & Depth r� X Depth ' septic system permitted if public sewer rs \\` 1 available within 200 feet-11 (� TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIRIADDlTION I ! DESTRUCTION l I { o sap j ►1 k Installation will serve: Residence L Commercial— Other tom- Number of bedrooms 3 Water table depth Number of living units: Character of soil to a depth of 3 feet: ICapacity-- ----- No. Compartments 3 SEPTIC TANK. 0 Type/Mfg i Method of Disposal t PKG. TREATMENT PLT. D Property Line, i Foundation � Distance to nearest: Well y � Total lengthtsize�--- LEACHING LINE j Cl No. a Length-of lines � Property Line t Foundation FILTER BEp C3 Distance to nearest: Well _��-- Number 11 Depth Sire SEEPAGE PITS Foundation� Property Line SUMPS L1 Distancestate laws, and to.nearest: Well-- - DISPOSAL PONDS Q I hereby-certify that khave prepared this'appl1ilcntion and that the work will be'done in accordance with San for Joaquin county this permit is issued I shall no ` rules and regulations of the San Joaquin County rfnrmance of the g; ,. compensation laws of California." Contractor's hiring or sub-contracting signature Home owner or licensed agent's signature certifies the ft towin i certify that a the pe employ any person in such manner as to become subject to workman's comps certifies the person u certify that in the performance of the work for which thispermitis issued, I shall employ parsons subject to workman's compensa .. followi tion laws of Calitnrniti." . The applicant must call for all required inspections.Complete drawing on reverse side. / =a 1 Date: f (�� AA Title: f Signed 7( ` l O DEPARTMENT USE ONLY © Z Date �-^ Area f Application Accepted by -pateZ' I Date ..F.inel.lnspection.by. Pit_or Grqut_Inspection by_- Additional Comments: Joaquin t Applicant - Return all copies to: SanEnvronmentaloliealthunty ublic Health vices Permit/Services 445 N San Joaquin, p O Box 2009, Stkn, GA 95201 ICK! PERMIT NO. T REMITTED AMOUNT . CASH RECEIVED Sy DATE FEE AMOUNT DUE _ INFO ' � � .•- /v7 ♦ EM 13.24 MCV.I/ 5S E41 1475