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12 � SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES v- �c, ENVIRONMENTAL HEALTH DIVISION I �i1� l gam, 445 N SAN JOAQUIN, PHONE (209)468-3420 SSCANNEDNo e I^moot3'3 P 0 BOX 2009, STOCKTON, CA 95201 0 2L. y2/ u PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) r 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 1$62 and the Rules and Regulations of San Joaquin County Public Health Services. Job Address tJ© a (Z - � d y�q R� City L 1 _ Lot Size/Acreage _J(�Q Q Owner's Name t 11 eA d eP-6G n"Ydress a Z :Z�60 A k-m 4Ma,2 w 0 RJ Phone 6? Contractor 11Address r1V N q! 61 License Noglqi-53 Phones&C? TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION O Out of Service Well PUMP INSTALLATION X SYSTEM REPAIR 0"' OTHER O Monitoring Well L • ® 7 DI AN-7�E-TO MARE-STF'S-EPTIC"TANK( b]2--e- SEWER LINES:"�—'^^- '�' -DISPOSA-L FL-D; ---PROP-L-INE + -. FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS /►d/t� INTENDED USE TYPE OF WEL"L"` PRO8LEM AREA CONSTRUCTION SPECIFIC TI)DNS °. yr n Industrial ��a n Bottom, O Manteca Dia. of Well Excavati Dia. of Well Casing 1 C7 Domestic/Private vel Pack D Tiacy l Type of Casings Specifications w--- i E ['I Public fl Odher✓ n Delta I Depth of Grout Seal Type Gropt e 6 Irrigation. �I ®,Approx. Depth I j Eastern Surface Seal Installed byj�� v1ej { Repair Work Done U Type of Pump/g I„f. H.P. State Work Done_ f Well Destruction ❑ Well Diameter, Sealing Material & Depth Depth - Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION*1-). REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is (� _7!4 available within 200 feet.) Installation will serve: Residence_ Commercial_ Other t Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth E. r SEPTIC TANK. O Type/Mfg I Capacity No. Compartments i PKG. TREATMENT PLT. ❑ ,f Method of Disposal Distance to nearest: Well Foundation Property Line f LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Poperty line r i ti SEEPAGE PITS 11 Depth Size Number j F SUMPS LI Distance to nearest: Well Foundation Property Line c DISPOSAL PONDS ❑ Ij i 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 person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contractin signature j certifies the following: "I certify that in the performance of the work for which this permit is issuedt'I shad employ persons subject to workman's ompensa- tion laws of California." I The applicant must call for all requir d inspections,. Complete drawing on reverse side. Signed Jl/_ h 16 ^^ Title: C / < t Date: OZ 3 C DEP RTMENT USE ONLY i Application Accepted by ln—� ,- Date i f• I i Area 2— 1 Pit or Grout Inspection by w Date Ea Final Inspection by Date 6- �3 r Additional Comments: j a Applicant - Return all copies to: San Joaquin County-Public Health-1,Jrvices /� `aP! JiCe Environmental Health Permit/Services �.K• / f�,e l CJ PC� P j 445 N San Joaquin, P 0 B 2009, Stkn, CA 95201 * i I INFO AMOUNT DUE AMOUNT REMITTED tCEIVED BY D;AT PERMIT'NO.IA/ r/-� ��3 ! INFO CASHt . EH'r3.21-24i n sl �..� . : _ _w _,f.. _., /]� �`EH 1126 = � V `ter , w ,