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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOA IN, PHONE (209)468-3420 IP O BO% 2009, STOCKTON, CA 95201 PERMIT 'F IRESII YEAR FROM DATE ISSUED (Complete in Triplicate) w I� work Application is hereby made.to San Joaquin County for a permit to construct and/or 62 and the Rules herein described. This application is made in compliance frith San Joaquin County Ordinance No. 51+9 and 1862 and the Rules and Regulations of San Joaquin county Public Health Services. I� if c city Lot Size/Acreage Job Address V 5 ��y� !� � fd Phone + Address Owner's Name -�- , m A !3s Phone 3 —Y/7 Jb Pim Address � �/0y�J"� License No. Contractor DESTRUCTION Gl put of Service We11 ❑ PLACEMENT C7 ` NEW WELL ❑ WELL RE Monitoring Well Ll TYPE OF WELL/PUMP. j SYSTEM REPAIR ❑ OTHER ❑ PUMP INSTALLATION SEWER 'LINES DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS AGRICULTURE WELL OTHER WELL FOUNDATION �- I _ INTEAIp£D_USE TYPE OF_WELk� __ PROBLEM AREA CO.NSTRUCTION_SPECIFICATIONS�_;�r- Dia. of Welt Casing Dia. of Well Excavation Cl Industrial f ❑ Open Bottom ❑ Manteca Specifications L7 Tracy Type of Casing_ CI Domestic/Private ❑ Gravel Pack Depth of Grout Seal Type of Grout I'] Public [1 Other !-1 Delta I i Irrigation r ..Approx. Depth ,I I Eastern Surface Seal Installed by H.P. State Work Done- Repair Work Done 0 Type of Pump Seaiing Material & Depth Well Destruction ❑ Well Diameterl Filler Material & Depth Depth 0 + sysperm (� TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/gDOITION I i DESTRUCTION I I ,vaiiabie�w thin 106 feet.) rl public sewer is c I 1 Installation will serve: Residence Commercial Other Number of living units: - Number of bedrooms Water table depth Character of soil to a depth of 3 feet;, No. Compartments ❑DType/Mfg k Capacity�l- SEPTIC TANK. y * Method of Dispose{ �g PKG. TREATMENT PLT. €I Foundation Property Line AVrAT Distance to nearest: Wel! EN�� Tatal length/size LEACHING LINE ❑ No. 8 Length of lines .k Foundation Property Lina MODE {' FILTER BED n Distance to nearest: Well ❑[.I ! t II t f7lii� lr t VICES I I Depth Size .Number i SEEPAGE PITS �r'.,I ZOf�Nfd"�4L F'EF;L7�1 D4V1Si0i�l f it Foundation , Property-f=ine } SUMPS Cl Distance to nearest: Well `€ DISPOSAL PONDS ❑ R Cher work will be done in accordance with San Joaquin county ordinances, state laws, and I hereby certify that l have prepared this application and that rules and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the it "I certify that in the performance of the work for which this permit is issued, 1 shall 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 certifies the following: "I certify that in the performance of the w rk for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." I The applicant mus call for all r quire ins coon_s. Complete drawing on reverse side. Title: - Date: Signed FOR!DEPARTMENT USE ONLY r r I Area ! (a Date Application Accepted by 12 Date Final Inspection by Data I Pit or Grout Inspection by Date - _ I I Additional Comments: kk r Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services t 445 N San�Joaquin, P O Box 2009, Stkn, CA 95201 CK DATE PERMIT'NO. FEE AMOUNT DUE AMOUNT REMITTED RECENED BY INFO . EK 17.24(REV,I I H 51 t� �+ V. l E ' EH 14.28