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AM s SAN `AQUIN COUNTY PUBLIC HEALTH ^ERVICES ENVIRONMENTAL HEALTH DIVIS 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This application 1s made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address I-7-�25 `raj- yiv J L- Cityr J�ro�O-Gr- Lot Size/Acreage _ Owner's Name—54 1L- &i`i L1k Si'1 Address S Z' 1 ,x t von. 4,,,4u/��rr t'1�Ct Phone b J CEJ Contractor 'O" Address �� m`�� `�r�'r� License No. Phone /6 TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT M DESTRUCTION ❑ Out of Service 71-11—0 PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER.a?1�5. ,�M gnitoring Well ❑ DISTANCE TO 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 n Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation 3 Dia. of Well Casing C*.l Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I'I Public (-I Other fl Delta Depth of Grout Seal - Type of Grout I I Irri aeon -ice Approx. Depth 1 I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. __ State Work Done _ Well Destruction O WeIU Diameter Sealing Material & Depth Depth > Filler Material & Depth TYPE OF SEPTIC WORK; NEW INSTALLATION i I REPAIR/ADDITION 1 I DESTRUCTION I I Mo septic syste milted if public sewer is availabl n 200 feet.) Installation will serve. sidence_ Commercial _ Other Number of living units: umhor of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK O Type/Mfg acity No. Compartments PKG. TREATMENT PLT. O Method of Disposal Distance to nearest: W Foundation Line LEACHING LINE ❑ No. & Length of i as Total length/size FILTER BED n Distance to as Well Founaatron Property Line SEEPAGE PITS 11 D h Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O _ I hereby certify that I have prepared this application and that the work will 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." Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa. tion laws of California." The applicant mpt, call,ffor all requited inspec ions. Complete drawing on reverse side. Signed X /v S uM Title: Date: 7 — FOR DEPARTMENT USE ONLY 12 l� Application Accepted by Date Area Pit or Grout Inspection C" ^ ate Final Inspection by Oath z � Additional Comments: ` Applicant - Return all copies to: San .} aquin County Public Health Services i1N-_ 242: Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED By GATE PERMIT NO. Page i/1 r,I ` ) � �e 11,EH 13-241REV.liner / li V� `/ ,�� G1 I� 7 I _ ,� f•J EH 11.20 F