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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �n 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 13O% 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t� (Complete in Triplicate) nd/ work in Application is hereby made,llan� JvithuSanCounty Joaquinfor CountyrOrdinenceconstruct lfo 5h9sando18628and thetall eRules andeRegulations daf San a application is made in comp Joaquin County Public Health Services. �D Giry P� Lot Size/Acreage E Job Address � 7 Q g 2/ ''j�'; / j as �d✓� Phone ��J �o 1 ! ,m L. a b eE' Q Address m Owner's Name r7 k � g2 / �� Lic�e No.��Phone � �413 Contractor �O e-f- �� Address``�l `� Service Well ❑ W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION TYPE OF WELL/PUMP: .. �+ Monitoring Well L7 + S BOTHER ❑ PUMP INSTAL CATION © SYSTEM REPAIR.❑ 6+ e SEWER LINES DISPOSAL FLD. PROP. LINE i DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITS/SUMPS FOUNDATION '.AGRICULTURE WELL , �.. a ., .. INTENDED USE TYPE OF WELL PROBLEM AREA CO INTENDED ' . Dia. of Well Casing L7 Industrial ❑ Open Bottom. A Manteca. - FA Dia. of WBII'ExcavationSpecifications ❑ Tracy _ -, .Type of Casing_ ( h CI Domestic/Private ❑ Gravel Pack y „ .. . Type of Grout �+ k Depth 8f'Grout Seal 4 6'� Public {1 Other � -� ❑�Delta Cp Vi' l I Eastern - �5urfaca. Seal Installed by kirrigation —Approx. Depth,, ; - State Work Done Repair Work Done U Type of Pump H.P. Sealing Material i Depth Well Destruction jj, Well Diameter ,#i e / u �. Filler Materiel 5 Depth ' Depth _ l stem TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION t I DESTRUCTION 1 l availableNo serwithin 200 feettled if public sewer is Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet'I I No. compartments SEPTIC TANK ❑ Type/Mfgq µ Capacity - - - Method of Disposal PKG.'TREATMENT PLT. E7 } Property�tine Distance�to nearest: Well Foundation t .t Total length/size LEACHING LINE ❑ No. & Length of lines Property Line FILTER BED ❑ Distance;to nearest: Well_ Foundation Number j SEEPAGE PITS` 11 Depth Size Number Pro Lina 3{ SUMPS ° Ll Distance to nearest: Well Foundation Property 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 Home owner or licensed agent's signature certifies the following: "I certify that in the performance,of-the work for which this pe�tnit is issued, k shall not employ any person in such manner as to become subject to workman's compensation laws of California.,' Contractor's hiring or subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,11 shall employ persons subject to workman's compensa• tion laws of California." The applicari` st call for all requir inspe tions. Complete drawing on reverse side Signed X Title: Date: �r 13 F R'DEPARTMENT USE ONLY" i r r. . Date Application Accepted by n Date_:Final Final Inspectian�'by � Date Pit or`Grout Inspection by r Additional Comments: j Applicant - Return all copr ies to: San Joaquin County Public Health Services r F� Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEECK RECEIVED 9Y aDATE PERMIT'NO. INFO AMOUNT DUE AMOUNEIREMIrTED CASH p o b p, /S3 . . Eli U-I4 IREY.i/M 5i ],f� EH tbZO,. W - - t