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I 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 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 Services. Job Address 1C1 1 i D�-a City Lot Size/Acreage + Address le E 1 $J QA�'�] Phone Owner's Name r i Contract �t C W Address \,L.1 CJ� -7(o License No. 7- Z� Phone (09+90 r TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well Cl PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitdring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE'bF'WELL_'PgOBCEMAREA "CONSTRUCTION SPECIFICATIONS` �- i C] Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation Dia. of Well Casing I Cl Domestic/Private ❑ Gravel Pack L1 Trac f y Type of Casing_ Specifications i'l Public Cl Other Cl Delta Depth of Grout Seal. .` Type of Grout I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by t II Repair Work Done L] Type of Pump H.P. " State Work Dona ._ Well Destruction ❑ Well Diameter Sealing Material & Depth, Depth -Filler Materiel & Depth'} TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR ODITION DESTRUCTION I i iNo septic syslem permitted if public sewer is available within 200 feet.) Installation will serve: Re dance_Y_ Commercial"— Other Number of-living units: Number of bed Character of soil to a depth of 3 feet: _ Water table depth SEPTIC TANK ❑ Type/MfgAAdh 4 Capacity-OAQ-_,-!�-No. Compartments PKG. TREATMENT PLT. ❑ w"Method of Disposal Distance to nearest:. Well Foundation "Property Line .i �. II LEACHING LINE No. & Length of lines - Total length/size k7 Q ? (h FILTER BED 11 Distance to nearest: Well Foundation Property Line S SEEPAGE PITS Jf4 Depth . _a5Si:e ; r a SUMPS LI Distance to nearest; Well Foundation_-..�.�_ Property Line A. �,�---- DISPOSAL PONDS ❑ Chereby Cenify that t have prepared this applidbtion'ana that the work will be done'in'accordance..with_San_Joaquin county-ordinances, state laws, and rules and regulations of the San Joaquin County v Home owner or licensed agent's signature certifies the following: "I certify that in the performance of.tfia wdrk for,.which this permit is issued, I shall not employ any person in such manner as to become subject to workmar)'i compensation laws of California."..Contractor's hiring orsub-contracting signature I certifies the following: "I certify that in the performance of the work for which this .permit is issuad, I'shafl-employ persons subject to workman's compensa- tion laws of California," {' f The applicant t call f 11 r aired inspections. Complete drawing on revers�eli rr � tf lA v Signed X Title: "+ f Data: FOR DEPARTMENT USE ONLY . Application Accepted b pp P Y 5 Data_11-2-3"�z Area �. cn_ Pit or Grout Inspection by Date Final Inspection byData 1�2,39 Z Additional Comments: �© S f A 4 1 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201FEE , i INFO AMOUNT DUE AMDUN REMITTED CK 11 RECEIVED BY DATE PERMIT N0. j EH 13-24(REV.rin51 /f EH 14.26 + (/