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�( SANYjAQUIN COUNTY PUBLIC HEALTH SERVI , ENVIRONMENTAL HEALTH DIVISION } �W41A ENT 445 N SAN jOAQUIN, PHONE (209)468- 3420 b RECEIVED P O BOX 2009, STOCgTON, CA 95207. � 4 2002 JAN �. PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . AI SAN JOAQUIN COUNTY (Complete in Triplicate) �� a lt.I�1; lTH SE�VICE Application is he;rtu�,n`-��.h*-�Q..,E,�11.��uin County for a permit to construct and/or iAaCa11 the work herein described. This application is taedei�ln �omplie.nce vith San Joaquin County Ordinance No. 549 and 1862 and.the Rulers and Regulations of San � I Joaquin Coun Publ Health Services. �ir�qA 0.V1-f c U d C, ltd Lot Size/Acreage Job Address v ) _ L d I'� 5Y,6 0-�-t 5 Phone t r �Oa Owner's Name ddress der✓, 311 if�sh s`(r� License No. �e fs3 Yte 5 Phor+t��r Contractor �V• ��` fdr`1 rn Address CA TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION [i Ou+ Service Well ❑ s I 140 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 4,,,rn DISTANCE 70 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 Dia. of Well Casing Cl Industrial ❑ Open Bottom C2Manteca Dia. of Well Excavation Type of Casing__5c 4e�u�r 0 p✓G Specifications El DomesticlPrivate ❑ Gravel Pack ❑ Tracy e T fyo. I'I Public F I4.,. -,3 [� Delta Depth of Grout Seat a r Typa of Grout 4 C P P-t 11 Irrigation 6;re�� fA ox, Depth I I Eastern Surface Seal installed by _ dv'fle✓ PPr p Repair Work Done 0 Type of Pump S uy �sr SIr H.P. State Work Done _ Sealing Material & Depth w� 1 ,4 c.4;a s Well Destruction ❑ Well Diameter r piper Material i Depth SII Depth , . TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIRIADDITION I I DESTRUCTION i I iNoavaseptic system hin m rented if public sewer is Installation will serve: , Residence— Commercial_ Other Number of living units: Number of bedrooms I Water table depth Character of soil to a depth of 3 feet: F SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments i Method of Disposal s PKC. TREATMENT PLT. G7 Distance to nearest: Well Foundation Property Line LEACHING LINE 0 No. Fr Length of lines T Total lengthlsize FILTER BED 0 Distance to nearest: Well Foundation .Property Line i SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well• Foundation Property Line DISPOSAL PONDS Cl I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, sista laws, and rules and regulations-of the San.Joaquin county Home owner of licensed agent's signature certifies the following: "I cavity 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." Contractoes hiring or subcontracting signature cartities the fonowing:''I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- j tion laws of California." ' The applicant must call for ail required inspections. Complete drawing on reverse' ideJJ _ Title: S s FeyfG is ase: ............'4 Signed X— F R�PAF1 ME USE ONLY ONLYApplication Accepted by ' Date Area Pit or Grout Inspection by date Fin Inspection by Date Additional Comments: rr /2-W Applicant - Return all copies to: &n Joaquin County Public Health Services Environmental Health Permit/Services !! 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 } FEE AMOUNT DUF AMOUNT REMITTED CASH RE EIVEO BY DATE K I PERMiT'NO. INFO it 561 : ,oO /C�� Z . EH 13.4(REV.ii9srl� �j V O ..