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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 f I 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 102S e- g/1 d-e ROAD City�� Lot Size/Acreage Owner's Name 5A ffi 4Q Z,4,v 0 Address S /Amis ZI Phone 4[.5�U � 1C2[�A1ov''T �y��y Contractor r Address �+ License No.:5 rV �_Phone JWl TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ t PUMP INSTALLATION I� SYSTEM REPAIR 0 OTHER ❑ Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK "f SEWER LINES DISPOSAL FLD. PROP. LINE A FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS q n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing {" Gestic/Private f ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications I•l Public Cl Other n Delta Depth of Grout Seal Type of Grout I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump ::9 H.P. //Z State Work Done {� Well Destruction ❑i Well Diameter Sealing Materialal Z& Dep �Lj_) f Iry E Depth Filler Material & Depth Ir TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION I I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 feet., fes`] Installation will serve:, Residence____ Commercial Other { i r f , Number of living units: Number of bedrooms Character of sail to a*depth of 3 feet Water table depth SEPTIC TANK. , r ❑ Type/Mfg l Capacity No. Compartments 1j PKG. TREATMENT PLT. ❑ Method of Disposal 1 `f Distance to'nearesi:--- Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED n Distance tri nearest:'- Well Foundation Property Line \1 I I o r f SEEPAGE PITS 3 l I Depth µ Size Number SUMPS 0 Distance to nearest: Well Foundation Property Line DISPOSAL PONDS 1 ❑ 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 cenifies 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 must call for all required inspections. Complete drawing one a si Signed X Title: Date: ' r� �� •� FOR DEPARTMENT USE ONLY Application Accepted by - --- Date —`� Area ` Pit or Grout Inspection by Date Final Inspection by Date i 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY INFO CK 8 DATE { P PERMIT'NO. , . EH13.24 MEV.t/1151 EH 1426 x