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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES , ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 I� P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED !� (Complete in Triplicate) Application is hereby made to San Joaquin Counti 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 Sere ces. Job Address -119 ,'wLr `"` 'ter &4�� r�(cfty Lot Size/Acreage 5Q art , r I' Owner's Nam Address .223� AA zaya. 77 Contract ` / ddress s `� 7(7 tT/_"icense No.KZ9Z7& PhorteCPD `,S'/U r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of service Well, ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK I SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM-AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom I ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing [I Domestic/Private Irl Gravel Pack ❑ Tracy Type of Casing_ Specifications I'1 Public C1 Other n Delta Depth of Grout Seal Type of Grout i I i Irrigation .__..Approx. Depth I i Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump I H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public sewer is r available within 200 feet.) Installation.will serve: Residence Commercial.— ommercial_ Other Number of,.living,units: _LNumber-of.bedr a s. 45'Character of soil to a depth of 3 feet: t Water table depth r' SEPTIC TANK: '9c�( Type/Mfg Capacity t- No. Compartments PKG. TREATMENT PLT.❑ 'r r r Method of Diosal Distance to nearest: Well '2O _ Foundation - Property Line __ LEACHING LINE No. & Length of lines .£ '� Tota! length/size r r r r FILTERfBECi ❑ Distance to nearest: Well ._`x-07!• Foundation 10 _ Property Line s SEEPAGE PITS 11 Depth t �. _Stitt . Number 11N./ r SUMPS '� y% Distance to nearest: Vllell, � Foundation-10 Property Line DISPOSAL PONDS ❑ ' ,f 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. - nn .- W ..,�, ,,,,�.�-._ - - Home owner-lir licensed ageriNs.signature certifies the following: "I certify that in the performance of the work-for which this permit is issued,_I shall not employ any pefson in such m neer as to become subject to-workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "f 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-Caiifornia." `x` The applicant m It - -for�all r Pec tions,.-Cyom" plete drawing on reverse side. Title: Dater 4 , FOR DEPARTMENT USE ONLY Application Accepted by Date t'4 -Z-132 Area Z- Pit or Grout'lFispection by Date Final Inspection by ' Data Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services t I Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 'INF AMOUNT DUE 1 AMOUNT REMITTED CASN YCEIVED BY E i PERMIT'NO. . EHt3-24 MEV.1ih5) / aj- Z EH 11.21 r