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SAN JOAQUIN COUNTY PUBLIC- HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 _ It 5 W. 4 t PERKIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This d 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. ; Job Address Cit Lot SizelAcreage s Actef Y Owner's Name T� 0949s4nlUel Address74 �+ n,, 7-C43 Contractor O�'t7Cf' ,t'J /��J`rJ Address (✓ 912 / � IO2 Phone 8�15619 _ License No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ - DESTRUCTION ❑ Out,of'Bervi-ce-Well-0, -- PUMP INSTALLATION.6_-_..,_-.,..,,.SYSTEM REPAIR,CI . _ ._OTHER '©z , Monitoring Well 0 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r' DISPOSAL FLD.' PROP. LINE FOUNDATION T AGRICULTURE WELL OTHER WELL PITSISUMPS INTENDED USE �� TYPE_��OF WELL PROB�EMAREA��CONSTFiUCTIO SPECIFICATIONS • -� f n Industrial ❑ Open Bottom; ❑ Manteca Dia: of Well Excavation Dia.of Well Casing t"E1 Domestic/Private Cl Gravel Pack t ❑ Tracy Type of Casing_ Specifications I"I Public 17 Other n Delta Depth of Grout Seal Type o.- rou t I Irrigation t--,Approx. Depth I I Eastern Q n Repair Work Done k Type of Pump H.P. l State Work Done�� rJ G Well Destruction ❑ Well Diameter Depth _ cl ,� �19e PL- TYPE /TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is , available within 200 feet.) Installation will serve: Residence Commercial_ Other ` Number of living units: Number of bedrooms # Character of soil to a depth-of 3 feet: " Water table depth t 4 SEPTIC TANK.i , i❑ Type/Mfg -'-*f Capacity_.,,.• No. Compartments PKG.'TREATMENT PLT. ❑ - Method of Disposal Distance to nearest: Well Foundation Property LineY� I ----PAYMENT l LEACHING LINE--' ❑�No. & Length4of linesTotal length/size ClIkett FILTER BED ' ❑ -Distance to nearest: Well Foundation Property Line - - I I N 21 1901 SEEPAGE PITS" J[A—'Depth Sire Number_- __ or SRI Ir urnr Ti l�sl-�-;,_,, --Qy SUMPS Ll Distance to nearest: Well Foundation Property LineENLL[RQNMFNTA, thLt-,L- h l i,V,-,O �DISP05AL_P.ONDS�-� -_❑ . _��., ,. _ ._-__--.---'--._wi-.-�- .._ .� _ __ -. � _ _. _ 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, antxT rules and regulations of the San Joaquin-County, t - '* `J 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 any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the.peiformance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant u �call'fo�Allutequke spe.io's. Complete'dfawing on-reverse sid Signed X Title: tQ .� Date: - R DEP M , Application Accepted by Date ` res Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: - i Applicant - Return all copies tt o: San Joaquin County Public Health Services I Environmental Health Permit/Services 445 N San Joaquin, P O Box 20og, Stkn, CA 95202 FEE INFO AMOUNT DUE AMOUNT REMITTED„ H RECEIVED BY DATE PERMIT'NO. . EHi3-24 19EV:T/'9sfw"y EH 14-26 V r O o t7 r O o �7 0