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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 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. Or G �G , G� City �' ecu Lot Size/Acreage Job Address ��rl F• IOS�rn+lr U d r �oK ( !� nr Address Phone Owner's Name sNe �,c 4.rv4 58"� C70�)�7�f-�� �� r f'11, p_0 License No. Phone Contractor _ Address �,�NEW WELyL' �' L REPLACEMENT"l l DESTRUCTION ❑ Out of Service kTell ❑ TYPE OF WELL/PUMP: 0 HER Q Monitoring Well #: '' PUMP INSTALLATION ❑ �ASYSTEM REPAIR L] 20 / �*+ SEWER LINES f 6 V-- DISPOSAL FLD PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK tr �aou gdTH1 R WELL 2- 6 d PITSISUMPS FOUNDATION r AGRICULTURE WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Welt Casing ❑ Open Bottom Manteca Dia. of Well Excavati, n - C) Industrial V(° SpecificationsG Domestic/Private )Gravel Pack L7 Tracy Type of Casing_ Type of Gro (7 Delta Depth of Grout Seal .}. i"1 Public fa Other tailed b JA+ I I Irritation _Approx. Depth I I Eastern Surface Seal Ins Y�7 t� —r- "` - G� H P State Work Done _ Repair Work Done 11 Type of Pump Sealing Material i Depth Well Destruction ❑ Well Diameter Piller Material 11 Depth Depth - 4 TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I afvailableseptic wthin 200 feet.) if public sewer is I installation will serve: Residence Commercial_ Other ILD Number of living units: Number of bedrooms Water table depth Character of soil to a depth of 3 feet: No, Compartments SEPTIC TANK ❑ Type/Mfg Capacity Method of Disposal PKG. TREATMENT PLT. ❑ Distance to nearest: Well Foundation Property Line Tom. mom • III l LEACIiING LINE Cl No. & Length of lines Total length/size f FILTER BED ❑ Distance to nearest: Well Foundation Property Line j �; t �4iliS11� Sire Number L. SEEPAGE PITS [ I Depth Props 1411E SUMPS CI Distance to nearest: Well Foundation DISPOSAL PONDS ❑ 3, - a 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 that in the performance of the work for which this permit is issued, I shall not Home owner or licensed agent's signature certifies the following: "I certify Pe employ any person in such manner as to becomes ject to workman's compensation laws of California."Contractor's hiring or sub contracting signature certifies the following:"I certify that in the perfar, encs of the work for which this permit is issued, 1 shall employ persona subject to workmen's compensa f tion laws of California." r ,.�,yturrh +✓ —Al"Jj �:� The applicant must call all required i 'c, Complete drawing on reverse side. ] Title: n• -s,�P1I� Date: Signed f FOR DEPARTMENT USE ONLY f t Date Area T 36 Application Accepted by �F �Q Date y Final Inspection by ` Data .Pit or Grout Inspection by - a Additional Comments: y Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services C 445 N San Joaquin, P 0 Box 2009, Stkn, GA 95207 �J FEE cK RECEIVED BY DATE PERMIT'NO. IFEE AMOUNT DUE AMOUNT REMITTED CASH � EM 13-24(REV,t i n 51 EH 14.20