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SAN 0 JUIN COUNTY PUBLIC HEALTH tVICES �• r,TI V I ROn-MENTAL HEALTH D I V I S I Oa. 445 N SAN JOAQUIN, PHONE (209)468-3420 L�� `L3 7l/ P O BOX 2009, STOCKTON, CA 95201 ._, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED oTpl.ete in Triplicate) 7gPo Al 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. 5k9 and 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. -76 Job Address r!�Q L i ^ Z � City Ln Lot Size6cres$ Owner's Name �� - Bar 4-0 Address _ Phone [ Consracto Address License No. Phone Gs-c?7 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT it DESTRUCTION ❑ Out of Service Well. Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OT J �( �II/Onitoyrfng 11 [3D157ANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLC PROP.�fNE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f� 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Wall Excavation Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications a 1'1 Public C7 Other (l Delta Depth of Grout Seal Type of Grout w (� I I Irrigation —Approx. Depth i I Eastern Surface Seal Installed by I Cly Repair Work Done LD Type of Pump H.P. State Work Done JNdfi�/� Z_C_��t_o it Well Destruction ❑ Wall Diameter Sealing Material i Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR►ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence— Commercial__._ Other r 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. Compartments PKG. TREATMENT PLT. ❑ ' Method of Disposal Distance to nearest: Well Foundation Property Line I LEACHING LINE Ll No. & Length of lines Total length/size -- FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Weil Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wiil 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."Contractors hiring or sub-contracting signature !^ certifies the following: "I certify that in the performance of the work for which this permit is issued, I shell employ persons subject to workman's compensa-tion Isws 'omia." The ap ,,an m tit call for all r uir i tions. Complete drawing on reverse side. 2, Signed Title: Date: 2hezf FOR7DA MENT USE ONLY Application Accepted by Date Area + Pit or Grout inspection by Date Final Inspection by Date Additional Comments: a — Applicant — Return all copies to: San Joaquin County Public health Services Z•�pr "y '"'" Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE F INFO AMOUNT DUE AMOUNT i1EMITTEO LASH I RECEIVED BY DATE PERMIT'NO. r F EH 13.74 IREV,I/N!1 \ Err 14.70 ! t /