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1U'1'L 1 C ATI UN FDR Z'EILM 1 1 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN , PHONE (209)468-3420 P O BOX 2009 , STOCKTON , CB 95201 . PERMIT EXPIRES I YEAR FROM DATE ISSUER (Complete in Triplicate) Application is hereby made to flan Joaquin County for a permit to construct and/or install the work herein described This application 11 Mde in caimpliance with San Joaquin County Ordinance Ho 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address 'Z r "O��T�tj420ael City -7 Lot bi se/Acreage Owner s Name FAl.L411"a DI i!t� Address - r16--A-110 /V;t .,,"_ —5-7/V Lys Phone •`��•5 �~ ,j Contractor � l' . tfG�tll►.Address PO g �� License No � .2-17/ Phone 7 l --97F13 TYPE OF WELL/PUMP NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ out of Service Yell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERA 5P Monitoring Well ❑ i 1 Ir•er!ri rl s DISTANCE TO NEAREST SEPTIC TANK SEWER LINES DISPOSAL FLD PROP LINE i FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Ll Industrial O Open Bottom ❑ Manteca Des of Well Excavation Du of Well Coming fl Domeettc/Private 0 Gravel Pack' 0 Tracy Type of Casing- Specifications f I PubliC 1-1 Other n Delta Depth of Grout Seal Type of Grout I I Irrrpation _ Approx Depth t I Eastern Surface Sent Installed by Repair Work Done L3 Type of Pump H P State Work Done _ Well Destruction 0 Well Diameter Sealing Material A Depth Depth tiller lilateria.l ai Depth TYPE OF SEPTIC WORK NEW INSTALLATION I f REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 feet 1 Installation will serve Residence _ Commercial_ Other Number of Wong units Number of bedrooms Character of sola to a depth of 3 fest Water table depth SEPTIC TANK ❑ Type/Mfq Capacity No Companrrients PKG TREATMENT PLT ❑ Method of Disposal Distance to nearest Well Foundation Property Line LEACHING LINE C1 No & Length of lines Total length/size FILTER BED n Distance to nearest Well Foundation Property Line SEEPAGE PITS 11 Depth Sae Number SUMPS LI Distance to nearest Well Foundation Property Lina DISPOSAL PONDS ❑ 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 regutmoone of the San Joaquin County Homs owner or licensed agent s signature candies the fonowing "I certify that in the performance of the work lot which this permit is issued 1 shall not employ any person on such manner as to become subpaci to workman it compensation Laws of California Contractor s hiring or tub-contracltnig aspnature undies the following 'I conity that on the performance of the work for which this permit is issued I shall employ persons subaect to workman a eampenaa loon Laws of California The spowma 1 lust call f r aN uiraid iyhpectoonl Compiete drawing onV1 versa side r ! Sigr,eLS ! �/� Title ri' i Date FPR DEPARTMENT LISE ONLY _ Applrestaori Accepted by Dais Area Pn or Grout Inspection by Date Final Inspection by Date Additional Comments _ Applicant - Return all copies to San Joriquin County Public Ilea1Lh Servicers I i- Environmental Health Pri-toit/Services 1 71' „ 445 N San Joaquin, p O Aon 2009. Stkn, CA 45201 C7PP ' 7, 1995 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED IV DATE PERMIT NO ;&771 /�/ 7//y — tw,.�a