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fl- SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 1 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 c PERMIT MIRES I YEAR FROM DATE ISSUED 7 (Complete in Triplicate) i 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. + --i Job Address S1 /Acreage 5 3M D 4 Owner's Name dress hone '� r oniraclar Mcense No, Phone TYPE OF WELL/PUMP. NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ Tf PUMP INSTALLATION - SYS EM EPA1R 0 . OTHER ❑ Monitoring Well h3( C7 DISTANCE TO NEAREST: SEPTIC TANK �5 '' SEWER LINES /00 DISPOSAL FLD.. PROP. LINO + FOUNDATION 15 AGRICULTURE WELL OTHER WELL---- INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M I strial ❑ Open Bottom ❑ Manteca pia, of Well Exca tion -Ia. of Well Cas' Bomestic/Private >6ravel Pack ❑ Tracy F Type-of Casing k $¢ecificaiions I'1 Public [--1 Other f Delta Depth of Grout Seal ypa Grou ri ation _.Approx. Dept Istern Surface Seal Installed by Repair Work Done 0 T p ype of Pum _ State Work Done _ Well Destruction ❑ Well Diameter - —.Sealing Material b Depth Depth Filler Material 3 De Depth •' � p TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION ( I DESTRUCTION I k {No septic system permitted if public sewer is r 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: SEPTIC TANK. ❑ Type ,'` Water table depth YP 9 Capacity_ No. Compartments PKG. TREATMENT PLT. ❑ .10, Method of Disposal Distance to nearest: Well Foundation Property Line E;y.. �w. `s f LEACHING LINE ❑ No. 8 Lenn,gth of lines Total length FILTER BED 11 "Distance to nearest: Well Foundation f Property Liner` � V G SEEPAGE PITS I I Depth Size Number i�en SUMPS !r Cl Distance to nearest: Well FoundationPr^, Line DISPOSAL PONDS' ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with`San Joaqu n/county ordinances, state laws, and rules and regulations of the San Joaquin County fs _,� " �;- - ---�"x -- _ Home owner or licensed agent's signature cern/les the following: "I certify that in the perform`ance_of�-tha w rk for,'vhich this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation Jaws of .Cbntracto's hiring or sub contracting signature certifies the following: "I ce ify that i perfor anc of the work for which this permit.3—i ssue , 1 shall California.'.' to P �c Y r ns subject to workman's compensa- tion iews;o f California." The applican It call r do s. Cu r on to side. Signe ` Title: Date: w — OR-DEPARTMENT-t1Sf.0_NLY� + 11r Application Accepted by Date i b~ 2 Arsa Pito Grou Inspection by uate Final Inspection-by Date Additional Comment:: � � ____�w �- fj• ,� -,,• .,l!� �!�S ��;(�(�£'..��, c� Applicant - Return all copies to: San Joaquin County Public�Health Services;' Environmental Health Permit/Seiv.ices' "445-N San -Joaquin,"p O Box 2049, S"tkn,CA 95201-1—"' LOS INF AMOUNT DUE, MMOU t REMITTED CASH RECEIVED BY DATE PERMIT'IYO. . EM 1 3.24 Mev.I/IS n �] /// G�f 1:H 14-26 C / f 0 L %dam