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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 fj,� ✓ P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) appliApplication is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This cation is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San oaquin County Public Health Services. Job Address City�t� Lot Size/Acreage Owner's Name ��Ltsl Address 62!6 , (,t/p�. A_,L , / Phoneto Contractor Address /6 7 c' License No PhoneT -9�0�.� TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT DESTRUCTION L) Out of Service Well Cl PUMP INSTALLATION O SYSTEM REPAIR O OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS O Industrial O Open Bottom O Manteca Dia. of Well Excavation Ca'Domestic/Private O Gravel Pack Dia. of Well Casing O Tracy Type of Casing._. Specifications I'1 Public (-1 Other fl Delta Depth of Grout Seal I I Irrigation _.Approx. Depth h I I EasternType of Grout L-' Repair Work Done T � Surface Seal Installed by ypl Pump H.P. — al State Work Done — • y'�'-�� Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is Installation will serve: Residence_-._ Commercial_ available within 200 feet.) Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK O Type/Mfg Water table depth PKG. TREATMENT PLT. O Capacity__________ No. Compartments Method of Disposal ►a Distance to nearest: Well Foundation Property Line LEACHING LINE O No. & Length of lines FILTER BED 0 Distance to nearest: Well Total length/size (� Foundation Property Line SEEPAGE PITS I I Depth T Size Number SUMPS Cl Distance to nearest: Well DISPOSAL PONDS O Foundation_______ Property Line --- 9 1999 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin y r rules and regulations of the San Joaquin County p � Home owner or licensed agent's signature certifies the followin 'l:'r:S ,'( F�b1 �31�14t#,`and employ an I work "I certify that in the performance of the work for fiv",,�r t' ppI �i d 1 F'i P Y e person g such manner i to become subject t workman's compensation laws of California." Contractor'sh�h�ring o�ubroo sub-contracting signature t Issued, I shall not certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ parsons subject to workman's com ensa- nature tion laws of California." The applican st call for all required inspections. Complete drawing on reverse side. Signed X Q l ~ 'a t ' �$ Date: G— FOR DEPARTMENT USE ONLY Application Accepted by „ter„ _ Z � Pit or Grout Inspection by Date Area Date—__,______ Final Inspection by Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Env tal Health Q ces 445iNoSannJoaquin, P Oe Box 2009, CA 95201 INFO AMOUNT DUE AMOUNT RE K � � � U REMITTED RECEIVED BY 4� DATE PERMIT'N0. 4 13.2 (REV.Iix5 114-26 ^ J