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� '� HEALTH DIVISION SAN AENVIRONNMENTALIN COUNTY PHEALTH UBLIC DIVIS�SeefrR ]*L PERMIT 445 N SAN JOAQUIN, PHONE (209)468-34 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to Seri 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. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health services. -- G' -iO LIC-Iq�Lot Size/Acreage Job Address 7 � � n LA,^1 ori City y� Owner's Name ` ' - T' C.n' _ Address Phone g r 'r Addressa7 1 R,I License No.9 V te6'70 Phone(. 5 7- � I ContfaclorOr b �ice 11 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of ery We Monitoring Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ C3_ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES - DISPOSAL FLD. PROP. LINE — FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS r 1 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y„ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation /o'/e ' o d. Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack ❑ Tracy - Type of Casing 5 c L. 14,- IQ A/O_ Specifications I'I Public I1 Other fl Delta Depth of Grout Seal 4/6 Type of Grout _ _ 1 I Irrigation na Nn f' STcwvT =nL• 7Q�Approx. Depth 1 I Eastern Surface Seal Installed Dy --�---d Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I ! DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial _ Other 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 3 LEACHING LINE ❑ No. & Length of lines - Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line ' SEEPAGE PITS 11 Depth Sire Number , SUMPS LI Distance to nearest: Well Foundation Property Line c- DISPOSAL PONDS ❑ 14, 1 j. I hereby conih that I have prepared this application and that the work will be done in accordance with San Joe in y ordinances, state laws, an rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for ich this permit is issu , I all 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 cenifies the following:"1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa. k, tion laws of California." The applicant caiI for all required inspections. Complete drawing on r rse ,sidle. 71 �, Signed X, �rin.+-e.. Title: � r"'" "r a��""A� Date: �P R�y F ARTMENT USE ONLY Application Accepted by Date I G �" ' `I Area Pit or Grout Inspection by Date I'21•q L Final Inspection by Date 4'2-9Z- Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO {C�`A�ySyH ��/� /J 2 . EM 1124 IREV.rr x sl 11t/[�J WA �� r _l•�cJ`� EH 14X