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SAN 01 QUIN COUNTY PUB 3EALTH 'VICES ENVIRONMENTAL PHONE (209)468+3420 445 N SAN JOAQUIN, P O BOX 2009, STOC%TON, CA 95201 pgRM T E%PIRES 1 YEAR FROM DATE ISSUID (Complete in Triplicate) Application Se hereby mede,to San Joaquin County for a permit to construct and/or 2. lee tall the Rules herein descr,Regulations This application Se made in compliance with San Joaquin County Ordinance Na. 549 and 1662 and the Rules and RegulaClor.s of Sa=— Joaquin county Public Health Services, Lathrop Lot Size/Acreage �— California Natural Products City Job Address Phone _------ —� li1�p Ci LA,'CYV('OD _ Address Owner's Name LL h� 7 pn.1 �(' _,1�0_Phol "`Q_�'� -- ,� ^^✓� �\CQ.✓I\� IIwO�� —L'cense No. �7 b� Address d DESrFUC71UN �� Out of Service well Contractor WELL REPLACEMENT .' OTHER ❑ monitoring NEW WELL CX TYPETYpE OPS SYSTEM REPAIR C1 PROP, LINE _�! PUMP INSTALLATION C r _ plgpOSAI f-L0.��-- SEWER LINES PITS/SUMPS t;LA ND '�.�Q_- t OTHER WELL DISTANCE TO NEAREST: SEPTIC TANK r AGRICULTURE WELL FOUNDATION Zn n PROBLEM CONSTRUCTION SPECIFICATIONS Dia. of Well Casing TYPE WELL Oia. of Well Excavation_--- pit(` SCH 40 _ INTENS ❑ open Bottom ❑ Manteca p�r� = Specifications---�-- ❑ industrial ❑ Tracy Type of Casing__--�-"-4E Type of GroutD r r W� j CA-Gravel Pack Depth of Grout Seal CCA Domestic/Privace I.j Other fl Delta I'I Public �rAPProx. Depth lxl Eastern Surface Seal Installed by I I litigation State Work Done _ Type of Pump H.P. _—" gepair Work Done U Sealing Material 5 Depth Well Destruction ❑ Well Diameter Filler Material b Depth 15 Depth —_— available within 200 feal.l TYPE OF SEPTIC WORK: NEW INSTAL ATION I I REPAIR/AOOITION DF.STRUCTIO rd INo septic within permitted it public rawer kPAYMEN 2 Installation will sane: Residence_ Commercial_ other kio��_ g� Number of bedrooms Water"_e�� p.41>jl Number of living units: No. Cg)p0 ^ Character of soil to a depth of 0 feet: Capacity__---- 4. 1 I ❑ Type/Mfg Meth SEPTIC TANK OUNTY PKG. TREATMENT PLT. ❑ Foundation Property$ IDA r Distance to nearest: Well PUBLIC HEALTH bERVICESVIy L` Total Iength'Ali ONMENTAL H AL H ❑ No. & Length Of lines Property Line LEACHING LINE Well Foundation FILTER BED ❑ Distance to nearest: Number Size —�— Property Line SEEPAGE PITS 11 Depth -- Foundation SUMPS LI Distance to nearest: Welllaws. and DISPOSAL PONDS ❑ application and that the work will be done in accordance with San Joaquin county ordinances. state I shall not I hereby certify that 1 have prepared this app rules and regulations of the San Joaquin County g: , certify . or which this rmit iron in such manner n to become subject 10 workman's compensation laws of California." Conte wor'ractor's luring or sub-contracting signature Homo owner or licensed agent's signature he certifies mance t to a work)for which this permit i issued, l shah employfPa<sOni subjecteto workman's compensa employie any Pe certifies the following: "I certify t tion laws of Calif a. The SPP licant at cel for all eq - e inspections. Complete drawing on reverse side. Data: 2 �Qj 112 — The . Title: Signed ARTMENT USE ONLY FOR DEQ ,�(,�.g�- Area V Date 3 a3 1 Date Application Accepted by � Final Inspection by Date Pit or Grout Inspection by Additional Comments: Environmental Health PPermit2Servi Stkn, CA 95201 ll copies to: San Joaqulb County Pulie Health Services Applicant - Return a ces 445 N San Joaquin, pERMITNO. CK RECEIVED BY DATE FEEF'�51 OUNT DUE AMOUNT REMITTED �7CASH C12�.I/ y��t y"�/,,� �[ �j 7 / T� INFO -0 2z(. I 1' l - �0 E `' CJEH Ia44(REV.V tial •OC l V EH 14-26