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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION r 445 N SAN JOAQUIN, PHONE (209)468-3420 is<o P O BOX 2009, STOCKTON, CA 95201 ' '�� New �twtiw IC-, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED k r (Complete in Triplicate} N �-`'v Application is hereby made to San Joaquin County for a application is made in Coe>pliance with San Joaquin Countyrmit to ordinancenstruct No. 549 ando1862etau and thee work Rules andein Regulationsdof Sans Joaquin County Public Health Services. Job Address City. �� Lot Size/Acreage Owner's Name + Address e O f Phone TT Contractor o,el ' I + Address /c T-2-4. AZA-1., U GG License No/( 1-3 73 P h o n ,Y(o "7l0 TYPE OF WELL/PUMP: NEW WELL D# WELL REPLACEMENT El DESTRUCTION Cl Out of Service well Cl PUMP INSTALLATION 9 SYSTEM PtFAIR ❑ OTHER ❑ Monitoring well DISTANCE TO NEAREST; SEPTIC TANK ., / C3 --�-. SEWER LINES �� DISPOSAL FLD. PROP. LINE -? U FOUNDATION a V r AGRICULTURE WELL - OTHER WELL - PITS/SUMPS - INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n industrial, O Open Bottom, ❑ Manteca Dia. of Well Ecava on rf - _ � .-_'�""`m ^.-`- {Tia. of Well Casing Domestic/Private --- -- I9(Gravei Pack ❑ Tracy Type of Casing ._ Specifications I'I Public is Other h1 Delta Depth of Grout Seal .- 00 I I Irrigation CrU' ype Gr ut 0�.1.__..Approx. Deyyq�Iastern Surface Saul Installed by -Repair Work Done L3• Type of Pump J H.P. �� Well Destruction ❑ Well Diameter Sealing Material & Depth State Work Dona T Depth t Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRlADDITION'I I DESTRUCTION I i INo septic system permitted if public sewer is Installation will serve: Residence— CommercialOche? available within 200 feet.) Number �- of living units: Number of bedrooms Character, of soil to a depth of 3 feet: SEPTIC TANK p Type/Mfg Water table depth PKG. TREATMENT'PLT. ❑ _ >.�.,� Capacity``- No. Compartments Method of Disposal j Distance to nearest: Well , R Foundation Property Line # J LEACHING LINE Cl No. & L•ength of lines ) r FILTER BED Total length/size Distance to earest. Well Foundation Property Line- ^ SEEPAGE PITS 11 Depth *Size � � Number SUMPS, r CI Distance to nearest: Well Foundation DISPOSAL PONDS ❑ r Property Line I hereby certify that I have prepared this application and that the work will b�done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin tea. 4 County _ Home owner or licensed agent's signature certifies the following: "I certify that Jn the performance of the work for which this permit is issued, I shat! not employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signaiure certifies the following: "I certify that in the performance rmance of the work for which this permit isissued, 1 shall employ persons subject to workman's compensa. tion laws of California." The applican at call for all required inspections. Complete drawing on reverse side. r Signed X T w Title: Dare: �-- FNT USEONLYApplication Accepted by �v� ��.FJDEPAIRT Date ~` Area ' IV 2 Pit or Grout Inspection b -� ate Final sped' by ate Additional Comments;t` A6`6 e1 1 ane SR A a c I a o n He to - 1 Cyt 1.�1r. ll.",F Environmental ealth Permit/Servicesf �2 4t 4,.,fp(e'd f/p U { 4 N San Joaquin, P. O-Box 2P09 Stxn, CA Tg520i C � /6)®r -.?20 r I A 1 d w4 Ce , FEE AMOUNT DUE AMOUNT REWTTE CK 4 rf t l0 INFO AMO "+ RECEIVED BY M CASH ��- OAT E PERMI7'NO. EM 13•YlfftEV.nasi F V � ` /7 /a - W At � 0 .ter - 9-1e) a