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v SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 � PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) r - 4 Application is hereby made to San Joaquin County 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 Services. ; lob Address 7-SM\ yam' Tz-, ,_} City ��,� b� Lot Size/Acreage Owner's Name �5 , Address ��= =•� } X11 GA 01,11 Phone }`Contractor - Address License No. Phone TYPE Of WELL/PUMP: NEW WELL❑ . ELL HEPLA CEME ED DESTRUCTION ❑ Out of Service Well Cl -PUMP INSTALLATION ❑ r SYSTEM R AIR ❑ OTHER ❑ Monitoring well ❑ DISTANCE TO NEAREST: SEPTIC TAW! SEWER LIN DISPOSAL FLO. PROP. LINE FOUNDATION. AGRICULTUR L OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL P40BLEM AREA C S UCTION SPECIFICATIONS r i t F1 industrial ❑ Open Bottom ❑:Manteca is, of it Excavation Dia. of Well Casing fa Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Cas _ Specifications Il Public C] Other F1-Delta -A- Grout-of-Grout- ealT� Type=of_Grout `J 11 Irrigation T .Approx. Depth 11 Eastern Surface Seal Instal by j Repair Work Done ❑ Type of Pump_ t P. tate Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth I Depth Filler Material i Depth ' TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l_1 DESTRUCTION INo septic system permitted if public sewer is I 9; available within 200 feet.l Installation will serve: Residence—S Commercial Other a Number of living units: Number of bedrooms' I Character of soil to a depth of 3 feet: �� E �� - Water table depth i SEPTIC TANK. ❑ Type/Mfg t t _J Capacity No. Compartments PKG. TREATMENT PLT.❑ j '-1 Method of Disposal r Distance to nearest: Weil Foundation Property Line 1 i - r LEACHING LINE D No. & Length of lines Total length/size F FILTER BED ❑. Distance to nearest. Well Foundation Property Line SEEPAG€ PITS 11 Depth Size Number SUMPS _ LI .Distance to-nearest: Well Foundation Propefty Line ALPONDS ❑ I hereby certify that I have prepared this application and that the work wilt 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 permit is issued, I shall not employ anypereo in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the folio in : 11 cartif that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa tion Is of Ca The applican us r r i tions. mplete drawing on reverse side. Signed X _ Title: �Sq L Date: 6 Z DEPARTMENT USE ONLY t E Application Accepted by Data res ` •e - Pit or Grout Inspection by Date Final Inspection by Dat Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CASH If CEIVED BY DATE PERMIT NO. INFO CASH j r . EH 13.24 Ip EV.t/K5) Sp �/ ` �� / �3 / eu 14,E