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��. • �3pr.Ir„ ,,...mf • ,,jN JOAQUIN COUNTY ?IJBLIC _T�ALTH ERVICES 3iVIRONMENTAL ii.EALTH DIVISION 645N 'AN .JOAQUIN , ?HONE (09)468—:1420 ? 0 BOX 2009, :;TOCBTON, L2A 95201 PERMIT E�IRES L YEAR FROM DATE "ISSUED . '..0[Rp l@LB 1u .:1�11C1LO/ ;.pplication is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This ippiicatlon is aside in ccopliance with San Joaquin County urcinstice ho. S 4 and 1862 and the Rules ano Regulations of San caqula County Public Health Services. 2,5"kov So. Chrlfmatn Rd Tra :.,:t S1ze/Acreage 9og .,ub Address3�21 'IV 'pDRW-Shrtltf6, p MarsaQR G2rnu( Deft,ny, �fchcei t"C% address %r P C+ �i33� =none ZO q42- OQ Owner s Name (I $ 261 En4arPC,It. Catnractor ust Hazmat address News*k CA 94560. License No.CSS- 5S 4`171 Phone 6io 414—a.n TYPE OF WELL/PUMPP. NEW WELL ^ WELL REPLACEMENT " DESTRUCTION L': Out of Service well ❑ PUMP INSTALLATION C SYSTEM REPAIR C OTHER C Monitoring well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 1TEND TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ¢fifth 5(ioaustn IllaU Q = Open Bottom �. Manteca Dia. of Well E:<avauonI e5 Ola. of Well Casing Domesuu Pnvate ECGravei Pack Tracy T1pe of Casino_Srh 40 Inc. Specifications tris Public Other i0 Delta Depth of Grout Seal Zr a sit Scree glc(Type of Grout n«u'MGM1� I 0-41 riq)auon 30—�41OApprok. Depth I , Eastern Surface Seal Installed by �C�zm ropcif Repair Work Done ._ Type of Pump H P. Stale Work Done _ Well Destruction Well Diameter Sealing Material 6 Depth Depth Filler Material i Depth _ TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i i DESTRUCTION I I INo septic system permitted d pudic waver is available within 200 loot.) Installation will serve: Residence _ Commercial _ Other Number of living units: _ Number of bedrooms Character of sue to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Companments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE :l No. g Length of lines Total length/rare FILTER BED .3 Distance to nearest: '.^le11 ounaauon Property Line SEEPAGE PITS I ] Depth Sire Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS C I hereby certdy, that I have prepared this application and that the work will be done In accordance with San Joaquin county ordinances, stale laws, and rules and regulations of the San Joaquin County Home owner or licensed agent'a signature umfies the following: "I cemty 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 apbleat to workmen's compensation laws of California." Contractor s hiring or su"ontractfng signature cemfies the following: "I candy,that in the performance of the work for which this permit is Issued. I shall employ persons suolect to workman's compensa- tion laws of California." Theeppliea use call for all a a,. C.o ipplate drawing on reverse sine. SignedX Title: FrLIHNdrogeo la-g15I Date: IDIS/� t ��n FOR DEPARTMENT USE ONLY / 9 Application Accepted by /r t O Ditto Area ( �� Pit or Grout Inspection by � Date T Final Inspection by 7n- Data QHS Additional Comments: k, l� 9 . 719 9 %pplicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services l / 445 N San Joaquin. P O Box 2009, Stkn, CA 95201 fEE AMOUNT DUE AMOUNT REMITTED CK s RECEIVED BY GATE PERMIlNO. INFO (� "Q CASH ��J� . EH 1314 IREV.i. sit I � // � l /) � �� I — /r t O� /6 a.S W Iooq,54