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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 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 I, application is made in compliance with Ban Joaquin County Ordinance No. 544 and 1862 and the Rules and Regulations of San Joaquin County Publicealtt4 Services. �r i �-(�t_o[�1 rD 1�1 I1 C-E-'4 E r6�_ i Job Address �Y U`'-- rol sT' City s Lot Size/Acreage } Owner's Name`S r• t10SIS , Address Phone Contractor)464 W . S�rjia Address I f UU icense No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 7.1 DESTRUCTION Cl Out of Service Well ❑ PUMP INSTALLATION, ❑ SYSTEM REPAIR OTHER Mo�rritorin8 Well L DISTANCE TO NEAREST: SEPTIC TANK dl N� SEWER LINES Gl � G,cJ DISPOSAL PLD.1�� PROP. LINE E �-i' I r� r FOUNDATION �p , AGRICULTURE WELL _��, OTHER WELL PITS/SUMPS JSI + INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Excavation Dia. of Well Casing XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of sing- Specifications 8 o2W ici -i"l Public r � Cl Other n Delta Depth of Grout Seal /D � Type of Grout E C�vl i I Irrigalio�2�1f� Approx. Depth X Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth i Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is { available within 200 feet.) I d 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 5 - {' Distance to nearest: Well Foundation Property Ling ' j LEACHING LINE ❑ No. & Length of lines Total length/size # FILTER BED ❑ Distance to nearest: Well Foundation Property Line 6 'I SEEPAGE PITS 11 Depth Size Number SUMPS Ll Distance to nearest: Well Foundation Property Line 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 signature certifies the following: "I certify that in the performance of the work for which this permit is issLied, I 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 work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of California." The applicant st call for all requ' ins pac 'o s. to drawing on reverse side. Signed Title: C A. "rkr Ce, S+o A 3 Date: FOR DEPARTMENT USE ONLY g�7 Application Accepted by Date �— L ` Area Pit or Grout Inspection by ate Final Inspection by Date ;�Lj Additional Comments: a �'l�� /J"!6, Applicant - Return all copies o: San Joaquin County Public Health Services 0 Environmental Health Permit/Services �f 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE / L' INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO." J I : 14.21[REv.Ifx51 FM EH 111-211 U � ffJl f 1 �