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' I 1 - I 4 SAN J 4QUIN 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 ISSUEDSCANNED(Complete in Triplicate) Application is hereby mad- to San Joaquin County for a permit to construct and/or install the Work herein described. This application is mad t in co61iance with Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Hea°�th Services. Job Address 1 _T '.Lot Size/Acreage JAC �s�.Sliti�c"7 Owner's Name kC { �� Address1Q C Phone Contractor s .� Address License No 7 2 9oPhon TYPE OF WELL/PUMP: Ih NEW WELL ❑ WELL REPLACEMENT ❑ DkSTRUCT10N ❑ t of Service Well ❑ PUMP INSTALLATION E3 SYSTEM REPAIR ❑ 15 OTHER Monitoring Well E �1 I DISTANCE TO NEAREST: SEPTIC TANK>� SEWER LINES >10D� DISPOSAL FL >4)�APROP. LINE>1-160i FOUNDATION ?lf�'F`�' AGRICULTURE WELL BOTHER WELLPITS/SUMPS 2100f-' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS N f•] industrial ❑ 0,pen Bottom ❑Manteca Dia. of Well Excavation �'r Dia. of Well Casing, - ` C] Domestic/Private ravel Pack Tracy Type of Casing Specif+cations y U] Public f:1 Other 13 Delta Depth of Grorou ut Seat Type of Gr I I Irrigation II.Approx, Depth I I Eastern Surface Seal Installed by Repair Work Done L3 Type of Pump __ H.P. Stateo,k P ne Well Destruction ❑ WeN�Diameter Sealing Material & Depth ' Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION f I REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is ill. available within 200 feet.1 Installation will serve: Residence_ Commercial— Other Number of living units: �M Number of bedrooms 1.A Character of soil to a depth of 3 feet: Water table depth (� ► SEPTIC TANK. ❑ TECapacity /Mfg No. Compartments 1 PKG. TREATMENT PLT. [l IMethod of Disposal, Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size h I FILTER BED n Distance to nearest: Well Foundation Property Line IIS � 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 Sari Joaquin County y Home owner or licensed agent•aF.signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not i 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 Khat 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 $t call for all r utred inspections. Complete drawing on reverse side. i Signed �I. Title: ` � Date: II FOR DEPARTMENT USE ONLY rG G Application Accepted by Date r0 9 7 / Area II ``IJJ� Pit or Grout Inspection by _... AC Final tnspectiontby� �"'�"L Date(E `L Xa _ Additional Comments: pplicant - Return all epics to. San Joaquin County Public Health Services #, Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE I INFO �A^MOU�Ne,T DUEAMOUNTREMITTED /CASH RECEIVED BY DATE . PERM17'NO. . EM 124 IREV.Iiw5) ](� f Q f Ez� y� . 1015-1, 7- 5 r Q EH 14.26 C! !! L