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,1 APPLICATION N COUNTY PUBLIC HEALTH SERVICES RONMENTAL HEALTH D I M S IONEN � , w �' ' 445 N S JOAQUIN PHONE (209)468-34 , {�;�. �'`'�f r11 2�� % 2009, STOCKTON, CA 95201 "C' �.•r' ��n l`/rE �'0# EiPIRES 1 YEAR FROM DATE SUED" _7 PM Z; A�4(,,11 (Complete in Triplicate) 6 A 1�k�EV oa ufp County for a permit to construct and/or install the vork herein describes} This a nnce frith San Joaquin County Ordinance No. 549 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address S �• A,-Poe-t- t City :!Aoc�,r<o Al Lot Size/Acreage ' Owners Name l o w< Cd__ Address 3Z-l) b �!'�e' S��et f1a 5907Phone /G —3 /�g Quarry l�r� B 961 oda g9a14�,, [so}4bZ-� Conllactor 4- 45SOCS 10-11S Address - S' License No one ' TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service dell PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER, Monitoring Well DISTANCE TO NEAREST SEPTIC TANK SEWER LINES ± 2.0 DISPOSAL FLO PROP LINE ± 3n` ' FOUNDATION _ 10- AGRICULTURE WELL At&— OTHER WELL-&&—_ PITS/SUMPS NA INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i! •% ❑ Industrial ❑ Open Bottom ❑ Manteca Ota of Well Excavation Din of Well Casing x•'4 ' n Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 4-0 P Specifications I I Public f l Other fl Delta Depth of Grout Seal ZO Typo of Grout ew.eat- I 1 Irrigation —Approx Depth I i Eastern Surface Seal Installed by t Repair Work Done U Type of Pump H P State Work Done_ Well Destruction ❑ Well Diameter Sealing Material A Depth Depth Filler Material i Depth 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 1 Installation will serve Residence— Commercial— Other Number of Irving 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 ' LEACHING LINE ❑ No & Length of tines Total length/size FILTER BED O Distance to nearest Well Foundation Property Line ' SEEPAGE PITS 11 Depth Sue Number SUMPS LI Distance to nearest Well 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 pariormance of the work for which this perrtut 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 California" The appltcan ust call for al r it inspections Complete drawing on reverse side P Sig Title ate ate FOR DEPARTMENT USE ONLY Application Accepted by Date - � Area Pit or Grout Inspection by Date Final Inspection by Date Odditional Comments Applicant - Return all copies to San Joaquin County Public Health Services 3s Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT CA G 4- —�R/rECEIVED BY D-A�7{T7E /g PERMIT NO �H 1324 JAEV 51 CH 14 25