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SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES 1� 9NVIRONMENTAL HEALTH DIVIS' MAY 3 44, SAN JOAQUIN, PHONE (209)4. . -3420 P O BOX 2009, STOCgTON, CA 95201 ENVIRONMENTAL j IEALTfI PERMITISERVICES PENT F Pi IES 1 YEAR FRQ-M DATE ISSUED 11 ,(rl }Jr (Complete in ) 2 J —) J0 1�4 Application is hereby made to n Joaquin County for d p.rmit too construct and/or install the work herein described. This application to made in ebmpSan with San Joaquin County Ordinance No. $49 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. 1 !i r 4, l ND ,, Job Address )Q(J)40-IC�Cr i r L 1\p„�(�V Q� T rqr n,r< C �y- - C Lot SizelACreage 11 Owner'sName Pr l_ �v,( .:1, I-�r*�I,; •?/PL7AdAress lihQ LrkC f l Oto ) JA h Tr'AhC 1 J( ri Phone 16 ) -67 / //Contractor d_51 -I) � Address r II C'trdl)✓c�r License No.� r vC-J�n_ / Phond 1�� • `�< TYPE OF WELL;PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION C1 Out OF-Service Well Cl PUMP INSTALLATION O SYSTEM REPAIR .N OTHER.'W-ei jo°, orintig Wgll 0 DISTANCE TO NEAREST; SEPTIC TANK wSEWER LINES ' Z DISPOSAL FLO.- L_ PROP. LINE FOUNDATIONAGRICULTURE WELL U OTHER WELL. L - PITS/SU/MPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Industrial O Open Bottom O Manteca Die. of Well Excavation h°'61a o/V1ell Casing f Domestic/Private Cl Gravel Pack _LS-TrScy Type of Casing_ Specifications- L _ I'! Public f71 Other fl Delta Depth of Grout Seal n > "� Type of Grout L ,/'t ". t 11 Irrigalron _Approx. Depth I I Eastern Surface Soul Installed by )r 7 Ile►- W Ranair Work Done U Type of Pump N.P. Stats Work Dons _ Well Destruction O WAIT Diameter Selling Material b Depth O Depth Filler Material li Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted it p,rblic sewer Is available within 2W feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Character of Boll to a depth of 3 feet: Water table depth SF_PTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT, O Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. 6 Length of lines Total length/size FILTER BED D Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ I hereby certify that 1 have prepared this application ohd 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 permlt Is issued, I shell not employ any person in such manner s to becomes iegt to workman's compensation laws of California." Contractor's hiring or subcontracting signature certifies the following: "I certify in the psft r( s'of the work for which this permit is Issued,1 shall employ persons subject to workman's compense- tion laws of California,'_ � The applicant ( elf►e d t s. Complete drawing on reverse side, l ) Signed Title: t ' c C/ �) FOR DEPARTMENT USE ONLY Application Accepted by Date ` —`� Area Pit or Grout Inspection by Date Final Inspection by Data Additional Comments; t-fin r Applicant - Return ail copleR to: San Joaquin County Public Health nervicont o. Q Environmental Health Permit/Servicee 445 N Ban Joaquin, p O Box 2009, Stkn, CA 95201 FEE AMOU T OLE AMOU HEMI"9b CK RECEIVED f!Y DATE PERMIT NO. INFO CASH tr, 1324tncv „�„ s- ------ - S-/213173