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I! SAN. JOAQUIN COUNTY PUBLIC HEALTH SERVICES „. r ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95203 _ f it Z I� 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 Ho. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health S rvi s. , f Job Address 2.39 City Lot Size/Acreage Owner's Name ° Address Phone 2 9�J �vq Contracto AMess` � L-icense-NTYPE OF,,WELLk � r NEW ELL ❑ WELL REPLACEMENT D DESTRUCTION LJ Out of Service Well Cl PUMP,.;INSTALLATION ❑. SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 ": DISTANCE TO NEAREST: SEPTIC TANK -'f SEWER L1NE5 ISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OT ELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA . CONSTRUCT -1FICATIONS ❑ lndustFial O Open Bottom. ❑ Manteca Ria. of I Dia. of Well Casing 1:1 Domestic/Private ❑ Gravel Pack C7 Trac; a 1A v T e of CasiSpecifications V1 Public C1 Other n Delta Depth of Gro Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Sea Installed by n Repair Work Done LJ Type of Pump H.P. f tat;Work Done _ �M Well Destruction ❑ Well Diameter '- Sealing Material & Depth f + Depth 's Filler Material & Depth TYPE OF-SEPTIC WORK: NEW INSTALLATION REPAIR IADDITION i I DESTRUCTION l I (No septic system permitted if public sewer is li available within 200 feetA t !!! Installation will serve: Residence J{L Commercial her 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. Compartmentsff, I PKG. TREATMENT PLT, ❑ , M -" a r-�" -A�' � A Method of Di osal w Distance to nearest: Weil Foundation Property Line s size- LEACHING LINE L1 Nos & LengtFo FILTER BED. n Distance to nearest:' Well ! Foundation _� rapert Line - F r -. r SEEPAGE PITS ', 01 Depth, J I. Sue N r`` Y SUMPS rLl Distance to neo est: Well Foundation U roperty Line DISPOSAL PONDS ❑ r I hereby certify that l 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 1 1. 'M 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 of 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." f '' 1 The applicant mu call for all r h d ins tions'Complete drawing on reverse side. # :, Signed t ` Title: l r , - Date- IM ate: - r'' �EPARTMENT USE ONLY e Application Accepted by Date f 3 A asA. { Pit or Grout Inspection by-'� x Date^ Final Inspection by Date v AdditionalLComrnsnts: A,,L ' Applicant - Return`all'copieslto• San Joaquin County Pub ic'Healtti Environmental Health Permit/Services . dI 445 P San Joaquin, P D Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIt'NO. INFO CASH ry R . EH 14-24 TREY,i i n$S �� 1�ca l o�-o 53 6_7 1�� 12"M 2 1 G ..-- EH 14.26