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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 S as. Job Address City LOdC Lot Size/Acreage Owner's Name VK �Lltf"S'tL1M� AddressPhone Contractor Address I'. Q� x License No. Phone 0(0-1 v us TYPE OF WELL/PUMP:: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION t of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR � OTHER Q� Motltoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS nIndustrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing wi omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications i'l Public EI Other n Delta Depth of Grout Seat Type of Grout I I Irrigation /�.Approx. Depth 11 Eastern Surface Seal Installed by �R, fl Repair Work Done A` Type of Pump .5�&.,6 H.P. I State Work Oone Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence e Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 fee . Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth SizeN'NNumber SUMPS LI Distance crest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 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 licen 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 n suc manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature certifies the to wing: "I c rtify that in the pe nce of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of alifornla." The apptic nt must or all omplete drawing on r sicla G Signed Title: Date: 12— ,(� l- FO DEPARTMENT USE ONLY Application Accepted by allt • V� — t.� _ Date Area 71 Pit or Grout Inspection by Date Final Inspection by ��'`e�-�� Date f �� Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, Box 2009, Stkn, CA 95201 FEE AMOUNT DUE A UNT REMITTED CK H RECEIVED BY ATE PERMIT'NO. INFO . EH 13.21 1REV.1 51 /;� 5 EH t/•2e