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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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 application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health 8ervii ea. SAA r Job Address 992- 2-- Q 2. City S Lot Size/Acreage P 4Owner's Name k Ar Address Phone u v 1 1�U� Contractor Address . S _Lice"e N s Phone 70 S TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT R DESTRUCTION D Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR El OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWERINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICU TUBE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL TRATRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ia. of Well Excavation Dia. of Well Casing Fl Domestic/Private ❑ Gravel Pack Type of Casing_ Specifications I') Public Cl Other epth of Grout Seal Type of Grout I i Irrigation w.Approx. De Iurface Seal Installed by Repair Work pone U Type of Pu State Work Dane_ Well Destruction ❑ Well DiameterMaterial & Depth Depth aterial & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1r REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is � � available within 200 feet.) Installation will serve: Residence s! Commercial— Other Number of living units: / Number of be rooms-.,3 p Character of soil to a depth of 3 feet y Water table depth SEPTIC TANK. O Type/Mfg 4 el Capacity f1 No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well LO- Foundation _ Property Line .211 LEACHING LINE ❑ No. & Length of lines Tottll length/size FILTER BED Cl Distance to nearest. Well oundation Property Line SEEPAGE PITS 11 Depth Z S 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 issued, 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 ust call for required inspections. Complete drawing on reverse side. r Signed Title: a- 2 yr` FR DEPARTMENT USE ONLY Date: Application Accepted by ► Date Area Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: 7T y Applicant - Return all copies to: San Joaquin County Public Stealth Services Environmental Health Permit/Services445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEEINFOAMOUNT D1JE AMOUNT REMITTED CASHRECEIVED BY DATE PERMIT'NO1�t a EH13.24 IREV.Y n 51 j J j