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SAN JOAQUIN COUNTY PUBLIC HEALTH SER ICES ENVIRONMENTAL HEALTH DIVISIC` 1.801` `. HAZELTON AVE. , P ONE (209)! 1--3420 - -� O BOX 2009, STOCKION, CA 95201 PERVIT RES I YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the vork herein described. This application is made in coupliance vith San Joaquin County Ordinance flo. 51+9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ! ,I 1- IL+[+� i Job Address `t DJ 4"+ t *%eAN t4Kf- l�od Cly Got Size/Acreage CA Owner's Name r°`r #� i�� ' Address 5lS W•T6'" .S kI'f rd CA }L30 Phone � s82-OZ-41 ��,.,��+ 3233 F4%4'1alcL ko, Conlractor[�kSZAddress w��-• rc;oJc- CA % License No.6!X4g75 Phone q/` R?9- 72_76 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEh ENT 0 DESTRUCTION Out of Service Well ❑ � PUMP INSTALLATION ❑ SYSTEM RE AIR ❑ OTHER ❑ Monitoring Well ❑ Q DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ! FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS El Industrial © Open Bottom O Manteca Dia. of Well E tcavation Dia. of Well Casing. Cl Domestic/Private Ci Gravel Pack ❑ Tracy Type of Casin Specifications I"I Public F.l Other n Delta Depth of Grot Seat Type of Grout I I Irrigation —.Approx. Depth I I Eastern Surface Soul I stalked by Repair Work Done 13 Type of Pump H..P. Sttp�te ork Done_ Well Destruction I. Well Diameter �`LL Sealing Material i th 'fon �ch[H mt 144 r Depth ._144 cra + Filler Material i Depth etS 4,li01t ! TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DES RUCTION I I INo septic system permitted it public sewer is available within 200 feet.l,a Installation will serve: Residence Commercial_ Other �r Y iz �f V Number of living units: Number of bedrooms RE t f Character of &oil to a depth of 3 feet: Water table depin 10 Y 7 SEPTIC TANK. ❑ Type/Mfg Capaci y No. Compartments 1 U 1592 PKG. TREATMENT PLT.❑ `�FXI O�? �: ;_ Method of�Disgp'sei Distance to nearest: Well Foundation Property LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line F i SEEPAGE PITS 11 Depth Size Number 3 SUMPS Ll 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 performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to become subject to workman's compensation aws of California." Contractor's hiring or sub-contracting signature h S 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 must call for ail requited _ineWtions. Complete drawing on reverseside. I f i Signed > �` ,�°� - `'� &r Title: LO(o JTs C�tG �riy• sV� 4,.�S Date: fol5I11- FOR DEPARTMENT USI ONLY �] Application Accepted by Date l0 Area 0-/C;" M.. {.� Pit or Grout Inspection by Date !U1 9Z Finalpe yDate E s coon b Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services, Environmental Health Pe Lit/Services 1601 E. Hazelton Ave., P 0 Box 20051, Stockton, CA 95201 t 7 QFEE a CK INFO AMOUNT DUE AMO/UNT/T REMITTED (C�AS9H/ RECEIVED BY / DATE PERMIT NO. j Elf 13"21IREV.1ins1 d U0! 1( if3 1� ! d�l r z gZ-,�5�S17 EH 14.26