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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I 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 is made in Compliance with San Joaquin County Ordinance No. 51+4 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. _ 1 Job Address / 1 Al`t V°v City Lot Size/Acreage .yy�� Phon"Zq1d4 200 t4?V/7- Owner's Name d Gs. ,dress Contractor Addresses _ _— License No. r Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 Out of Service Well ❑ PUMP;INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUND AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA SPECIFICATIONS _,.❑_Industrial._., ❑ Open Bottom— ❑ Manteca Dia. of Well Excavau Dia. of Well Casing C) Domestic/Private ❑ Graz pack ❑ Tracy Type of Casing_ Specifications Cl Public i I-1-Other n Delta Depth of Grout Seal a of Grout (� _ t I I Irrigation .Appras, Depth I I Eastern Surface Sedi-Installed by 3~� �+ Repair Work Bone U'` Type of Pump• H..P. s State Work Done + Well Destruction ❑ Wall Diameter Sealing Material & Dep'th Depth =Filler lifeterial t Depth _ TYPE OF SEPTIC WORK: NEW INSTALLAr IO REPAIRIADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is j available within 200 feet.) , t tt Installation will serve: Residence— G ommercial� Other - t d , r Number.of living units: Number of,bedrooms y, Character of sail to a'depth of 3 feet: ) Water table depth SEPTIC TANK� X Type/Mfg r � Capacity _ No. Compartments PKG, TREATMENT PLT. 0 .t` Method of Disposal Distance to nearest:11 Well r Foundation Property Line -� t r LEACHING LINE ❑ No. & Length of lines - Total length/site FILTER BED t Distance to nearest: Well Foundation Property Line SEEPAGE PITS �I I• Depth Size �' Number SUMPS Lt Distance to nearest: Well Foundation Property Line 1 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 regulations of the San Joaquin County _ Home owner or licensed agent's si nature certifies the fallowing; "I certify that In the performance of the work for which this permit,is issued, I shall not J employ any person in such manner is to subject to workman's compensation laws of California.',r,Contractofts-hiring or sub-contracting signature l certifies the followin - "I Certify tha in th perto ante of the work for which this permit sued I shall employ persons subject to workman's compensa tion laws of Californ a." w The applica must call r 11 requ ed i pectin Comppplete drawing on reverse si Signed X 1 ride: `i Date: FOR DEPARTMENT USE ONLY S I Application Accepted by_ -AVZ � "" Date S- /' Area r r Pit or Grout Inspection bye+ 4 Date Final Inspection by Dat , :� eIv Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services - fi•� 445 N S oaquin 0 Box 2009, Stkn, CA 95201FEE r e, I INFO AMOUNT D,�U�,,E�{^^�� A//MOUNT RAE/MI� E CASH RECEIVED BY DATE PERRMIT NO¢.a �` . EH 1]•21(ltEV.1/N51 it�[�v"V � �'"[.f b ��,J'�DQ✓ . EH t4-se f