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SAN JOi-4UIN COUNTY PUBLIC HEALTH S}%on'ICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CASA+fU1-N(�OLTNTY-PLIC HEALTH SEMI PERMIT EXPIRES 1 YEAR FROM DATE IS�TJEDIDNON AL HEALTH DIVISION (Complete in Triplicate) SPECIAL PERMIT 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 end Regulations of San Joaquin County Public Health Services. Job Address CEMIPMAY t.^J• /`fie Cioyb Avg, CitySTI&CAMAJ Lot Size/Acreage %0 X lSW C00lgr PoRnni4 4r,Owners Name � � '0 S 0C 1:-"-J Address D CKie_y GA. .75:21-3-9001? Phone06-7 —3-CO C e'v 7, AST-' J r=rZR Y CO—rO rV Contractor Sf>;FC �LrM Address WS My�Cc ) S�C'�'0'� License No.s/ �� PhLie Cp')ybS_ l TYPE OF WELL/PUMP: EWE L I" WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INAAL� N SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES uNrwo�v� DISPOSAL FLD. PROP. LINE �d FOUNDATION /C r AGRICULTURE WELL !!4 OTHER WELL G�_ PITS/SUMPS � ,4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , CI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation b Dia. of Well Casing aZ IM Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ T?/ Specifications SC'+- yU I'I Public MC: p, Other n Delta Depth of Grout Seal S� Type of Grout^�j`�C�_^ I I Irrigation `' `_v Approx. Depth XEastern Surface Seal Installed by S r'��C ;�?r✓M Repair Work Done L3 Type of Pump H.P. State Work Done_ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth dr� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 1 I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms �v - Character of soil to a depth of 3 feet: Water ablTe�i $ ` SEPTIC TANK ❑ Type/Mfg Capacity No. Cehh>tin s PKG. TREATMENT PLT.❑ MethMAT'"'1992 Distance to nearest: Well Foundation Property L' Jp iQUNTY _UL,L_TG LEACHING LINE 0 No. b Length of lines Total lengtt" 1 DIVISION FILTER BED O Distance to nearest: Well Foundation Pro arty Line ��A&M COUNTY-PUBLIC HEALTH SERVI SEEPAGE PITS II Depth Size Num �1�i TAT TSH�DIVISI SUMPS LI Distance to nearest: Well Foundation `9�'�I-A-�ERMIT 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 California." The applicant m call for all r P gside.-(-' p aqui nspectio s. om 1 drawing on reverse 2 Signed ` Title: Ga. Date: 3 , T FOR DEPARTMENT USE ONLY /p,/.,� Application Accepted by Date - Area_ . c, Pit or Grout Inspection by D to Al _JFinalJlnspection by Date 'S`�Z'`lZ Additional Comments: /''CXLCJ Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services �pl 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201FEE INFO AMOUNT DUE AMOUNT REMITTED CK 9 CASH RECEIVED YY DATE PERMIT'NO. . EN U•24 IIIEV.riNsr 12,92 lrl�b b EH 11.20 7