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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION X445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT 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 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. ,;Z31;0 0ty 7 C Lot Size/Acreage Job Address (� /10,0 v ? Nr /1�r2,0 Q.Q r t�r�)Q 1 o a - Phone Owner's Name Address C K3 K11 Contractor L4•r Address 0 -License No. Phone WELL REPLACEMENT [.1 DESTRUCTION DESTRUCTION Out of Service Well TYPE OF WELL/PUMP: N W WELL ❑ ❑ PUMP INSTALLATION C7 SYSTEM REPAIR C1 OTHER 11 Monitoring Well L� DISP-OSAL.FLD. PROP. LINE. _T DlS7ANGE TO NEAREST: SEPTIC-TANK •�-' =- SEWER LINES-;3��_�- 1 --- FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing n Industrial 0 Open Bottom ❑ Manteca Dia. of Wall Excavation SpeCitir ations C_1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Seal Type of Grout Depth of Grout Sea CI Public Cl Other Cl Delta , I Irfigation _._.Approx. Depth I I Eastern Surface Se Installed by L� H p. State Work Done Repair Work Done U Type of Pump gelling Material & Depth Well Destruction [3 Well Diameter Filler Material & Depth Depth TYPE OF S€PTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ] DESTRUCTION I I availableiw thin 200 feet.lstem ed if public sewer is 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 Ca SEPTIC TANK ❑ Type/Mfg pacity No. Compartments EE4 Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: --Well_ Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED Cl Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number - SUMPS Ll Distance to nearest: Well _ Foundation r Property Line - 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, an k rules and regulations of the Sen 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 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 perbrmance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant mustII for all r quire ti ins ecptons. Complete drawing on reverse side. ,w Signed X Title: �� A>1Ii `P I Date: FOR DEPARTMENT USE ONLY / � � Application Accepted by -- -- Date Area - Pit or Grout Inspection by Dale Final Inspection by Date AL03- 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 PEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. I INFO R L; CASH oa . EH 13-21IREY.1lM51 [`r Em 11.25 - .