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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 20093, 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. Joh Address _ a`--x5- 27-09 City Lot Size/Acreage owner's Name K2�LJJ..t�- "�'7-e�YV1S- - - Address [�C t,?SL� Phone j] Contractor ,�7R7 Address - von';" License No.,i2we,_Phone TYPE OF WELL/PUMP: INEW WELL ❑ WELL REPLACEMENT C�l / DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR $dam OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack 44racy Type of Casing_ Specifications VI Public !-1 Other rl Delta Depth of Grout Seal Type of Grout I ngation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done type of Pump `�W_r�� — H.P. 15f) State Work Done Vi rw-a Well Destruction ❑ Well Diameter �� 1 Sealing Material i Depth Depth �VL1/A' Filler Material 8 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION ( I DESTRUCTION I I INo septic system permitted if public sewer is available within 200 feet.) "4 Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms (t Character of soil to a depth of 3 feet: Water table depth v SEPTIC TANK O Type/Mfg Capacity a PKG. TREATMENT PLT.❑ ro, um Distance to nearest: Well Foundation Prop8j; 111111111 how LEACHING LINE C1 No. & Length of lines Total length/size FILTER BED C1 Distance to nearest. Well Foundation EWROMMENTAI HEALTH PERM44 ERV!C ES SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 perso in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the fol) ng: "I certify that in the p ormance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of C rnia." The appli ant st call f a! requi I ctions. Complete drawing on r or side. Signed Title: A Date: DEPARTMENT USE ONLY Application Accepted by Date `3 4 Area Pit or Grout Inspection by Date Final Inspection by Date t-;? 3 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CCK RECEIVED BY DATE PERMIT'NO. EH13.24 IaEV.t i n 51 EH 1425 [ [ f� t�/'� ref'• �'i�7