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Y SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 A"X-Td6 Z_0-32J`9-D3 PERMIT EXPIRES 1-YEAR FROM DATE ISSUED y�l ✓lN�YI97tr>?S Q Co let in Triplicate) Application is hereby made San Joaquin Count for a permit to construct and/or install the work herein described. This application is made in ctmlpliance with San Joaquin County Ordinance No. 549 and 2862 and the Rules and Regulations of San Joaquin County Public Health Serv_tcea. � E Pae tsuS F�,lLrn f r 90- 323 Z d 1a 10W 5LCr_X cr_. H16Aw mi-Y /Zf� Job Address �T N �y3 Z city. 1�°17''JCJ4 Lot Sire/Acreage Owner's Name �STlrf�lG XNG r Address 708 E, Q_-Orn1TF &V E. 1 e -/0-930` Contractor-�m a►`' ddress E -!Rlecense No.Jif $ Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION El SYSTEM REPAIR ❑ OTHER -R LJ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PRGP 1.101= ,004L-Z- �r-1 FOUNDATION AGRICULTURE WELL OTHER WELL INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 4w-ZdP1 Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation (4.- aLJ_ to t7 Domestic/Private Cl Gravel Peck ❑ Tracy Type of Casing_ -spee"848-9 I'1 Public M Other ❑ Delta Depth of Grout Seal zee-e4-6reat eu, I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Weil Diameter Sealing Material & Depth I Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if 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 SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest:. Well Foundation Property Line 14 LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest. Well Foundation Property Line n �1. SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Welt Foundation 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, 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 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 performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califomia." The applicant must call for all required inspections. Complete drawing on reverse side. Signed X I.- L�� _ Title: Fes, 45064.a& Date: F EPARTMENT USE ONLY Application Accepted by data � ea Pit or Grout Inspection by � Date Final Inspection by - �' Dattel Additional Comments:0�' �-f'<<��is��f¢-� �e�/ {f�Pod� �'�'t�'sO.c��✓E.T� F'Gr'9[ 'GG`�'! �!� 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 REMITTEDC K H RECEIVED BY DATE PERMIT'ND. INFO • EH 13-24 1REV,�i n 51 InoOaf �jI&CO q PERMIT EH 1/.2a L�