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SAN- JO COUNTY PUBLIC HEALTH SERVICES SANT ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (2CA)g5201420 P O BOX 2009, STOCKTON, i k MIRES 1 YEAR FROM DATE ISSUID l PERMIT E� licate) (Complete in Trip 6 for s P lotions of San uin County permit,to construct and/or install the work herein describe Applicstion is hereby made.to sen JO84 ication is made in compliance with sen Joaquin County prdinsnce No. 5�9 and 1862 and the Rules and Regulations Joaquin public Health Services' S,e� �r�ty Lot Size/Acreage Josquia County �Ad 31.lob Address Phone EZ7-A �S :-�� }, Owner's Name I fJ �J I f� 13 License (y ��—t of service Well ❑ J`�-j� Address Q� DESTRUCTION Contractor WELL REPLACEMENT C7 Monitoring Well NEW WELL ❑ OTHER ❑ TYPE Of WELL/PUMP: SYSTEM REPAIR 0 PROP. LINE PUMP INSTALLATION ❑ DISPOSAL FLD.— SEWER LINES PITSISUMPS DISTANCE TO NEAREST: SEPTIC TANK ��-� OTHER WELL�--�— FOUNDATION .��---� AGRICULTURE WELL �-�— TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Wall Casing INTENDED USE ❑ Manteca pia. of Well Excavation ---- C3 open Bottom Specifications �+ f_l Industrial L7 Tracy Type o1 Casing_ Type of Grout C:1 Domestic I Private ❑ Gravel Pack Depth of Grout Seal I.1 Other "I fl Delta i'1 Public Surface Seal Installed by APProis. Depth I ! Eastern } I V Irrigation rtate Work Done rk Type of Pump `— H.P.P Repair Work Done U Sealing Material & Depth �416 A, f _1 Well Destruction ❑ Well Diameter Filler Material & DePth W Depth n — tic system permitted it public sewer is i available.within 200 1eet.i TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR1AgDITIONyi i` DES I I o seP F } Residence idence Commercial— Other Installation will sery �- -t' ._ _ . .�. O ..�,._Number.of bedrooms _ —,� r � �" Water table depth Number of living units:. •�-� -- C Character of soil to a depth of 3 feet: Capacity._--- No, Compartments C� SEPTIC TANK ❑ Type/Mfg Method of Disposal f PKG. TREATMENT PLT. ❑ .1 Foundation �---- Property Line p Distance to nearest: Well�--�— is - Total lengthtsize 4 ❑ No. &;Length of lines Properly Line LEACHING LINEFoundation — l ir Well�� - FILTER BED C7 Distance to nearest: Size Number SEEPAGE PITS l 1 Depth Lina ��----- E SUMPS LI Distance to nearest: Well ��- Foundatian�.== Property DISPOSAL PONDS ❑ application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that I have prepared this app r, rk for which this rinnit is iss shall not u rules and regulations of the San Joaquin County wing:folio Home owner or licensed agent's signature corlme subjects to orkman'srlcornPonsation laewsoof California`Colotape�sons sung bject p to workman's eompensa� F employ any person ub-contra i in such manner as to bac certifies the following: "l certify that in the performance of the work for which this permit is issued, I aha employ I tion laws of California." ' a I The applicant must u for all required inspections. Complete drawing on reverse side. µ Y� Dat ST 13-q3 F f 14 s �" Title: t Signed ti F p DEPARTMENT USE ONLY t Date Area I Application Accepted by Date _� Final Inspection by pate Pit or Grout Inspection by Additional Comments: San Joaquin Applicant - Return all copies to: Environmental unty Public vices �_z Health hermit%Services P',Ol3 � ox 2008, Stkn, CA 95201 445 N San Joaquin, CK, °' RECEIVED.9y DATE PERMIT NO. FEE AMOUNT DUE AMOUNT REMITTED CASH - {, INFO �a QQ 6? Or aim l3� ' SAY . EM 13-24 tREV.I/ EH 14.26 t -