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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES
<br />ENVIRONMENTAL HEALTH DIVISION
<br />445 N SAN JOAQUIN, PHONE (209)468-3420
<br />P 0 BOX 2009, STOCKTON, CA 95201
<br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED
<br />(Complete in Triplicate)
<br />Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This
<br />application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San
<br />Joaquin County Public Health Services.
<br />Acreage ,.-.CA JO Address colp L) i J''', , srboil-K i . ‘..iLy -.=.34-- - -
<br />
<br />(51-..6-11-:ila, 11-744-10.`—' Address a5-61 3 1kt, Pa,641 /ea'', ae,04.e. 34,?- 2c 9'7
<br />Owner's Name
<br />../ ,--i. 0-0- Pa BOX O 7e License No.-73 776 Phone contracioAum 1,41/04(..‹. otzdtA Addre ss
<br />TYPE OF OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT Ei DESTRUCTION L'..1 Out of Service Well
<br />'.i.... Monitoring Well
<br />0
<br />c3
<br />PUMP INSTALLATION 0 SYSTEM REPAIR Ei .'OTHER 0
<br />SEWER LINES DISPOSAL FLD. - PROP. LINE _____ DISTANCE TO NEAREST: SEPTIC TANK
<br />WELL OTHER WELL PITS/SUMPS _ \ FOUNDATION AGRICULTURE
<br />INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br />Casing
<br />U Industrial ID Open Bottom 0 Manteca Dia. of Well Excavation - Da. of Well
<br />Casing_ Specifications 171 Domestic/Private LI Gravel Pack ,..73 Tracy Type of ,
<br />Depth Grout Seal 'i, Type of Grout [I Public 0 Other II Delta of
<br />Surface Seel Installed by \ :. I I Irrigation _ Approx. Depth I 1 Eastern . -
<br />0 Type Pump H.P. r , State Work Done Repair Work Done of
<br />Sealing Material & Depth "1
<br />Well Destruction 0 Well Diameter - ... ‘, ../., .s. Filler Materiel & Depth _
<br />Depth ,
<br />TYPE OF SEPTIC WORK NEW INSTALLATION I I f3 A)/ADOITIONThi41 DESTRUCTION I ..1No.septic.system•permitied if public sewer is
<br />. available within 200 feet.)
<br />i-'
<br />Installation will serve: Residence Commercial t r . .... r
<br />Number of living units: / Number b rooms .. ; ' ( _ ,
<br />3 feet: W-ater'table depth II C) 0 -1-- Character of soil to a depth of
<br />Type/Mfg --1---9.--,Z) Capacity No. Compartments SEPTIC TANK. - ,..;.-.,0 ,,-,.P-f._-*S4t,_. -..._.
<br />f ' • -Method of .Disposai PKG. TREATMENT PIT. 0 ..---' ( -.
<br />Distance to nearest Well -..) 0 Foundation .' / 0 Property Line 4-- 4
<br />,.,.
<br />/ -, 1 /
<br />- * lines Total length/size 4-/O r 2
<br />LEACHING LINE No. & Length of ,---- ,i4. . , .
<br />0 Distance to nearest: Well 7 ' Foundation /0 11- Property Line FILTER BED .3 ,-" ,
<br />r h --,
<br />SEEPAGE PITS `7,4.e Depth 5-. Size 3 Number i / •
<br />LI Distance to nearest: Well 100 f 4 Foundation /0 4 ' Property Line .•4-- -f SUMPS • .-,
<br />hiclonAll orwrIA ...— n
<br />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
<br />rules and regulations of the San Joaquin County
<br />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
<br />employ any person in such manner as to become subject to workmen's compensation laws of California." Contractor's hiring or sub-contracting signature
<br />certifies the following: "I certify thatin the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa-
<br />tion taws of California."
<br />The applicant must call for re ired inspections. Complete drawing on reverse side
<br />Signed X Title: P D at e: r23o ?z
<br />FOR DEPARTMENT USE ONLY
<br />Application Accepted by 4P12,7&-t Date /6 —q 2. Area
<br />Grout Inspection by
<br />Additional Comments:
<br />Applicant - Return all copies to: San Joaquin County Public Health Service
<br />Environmental Health Permit/Servicee
<br />445 N San Joaquin, P 0 Box 2009, Stlin, CA 95201
<br />FEE
<br />INFO
<br />5 A
<br />AMOUNT DtJE AMOUNT REMITTED CK 0
<br />CASH RECEIVED BY DATE PERMIT NO
<br />s-M . z/- e 6 (LfcO
<br />. 11A14.10
<br />z--
<br />ate 043 Inspection by INIa4P Data in-2,3-9
<br />EH 13-24 IFIEV. 5 )
<br />EH 14-25
<br />s6)'
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