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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES w - ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 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,Co� Or ina��549 and 1862 and the Rules and Regulations of San Joaquin Count Public Health Services. ��TT,//��,rL,, „_— , Job Address �` � 0�3�- City l Lot Size/Acreage Owner's Name , ' Ikt Ls-�o S r�tDyt Q I�l—.4lGddress z2 zz-s /��'�'�f�— AI v PA Phone '-3 6 041 Contractor is bvlt f �44 Address -41L-S License No. Phone TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLAT N O SYST REPAIR O OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WEL OTHER WELL, PJTS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation — Dia. of Well Casing omestic/Private XGravel Pack O Tracy Type of Casing_ Specifications ("I iblic 1.1 Other (� Delta Depth of Grout Seal � pe of Grout �I igation pprox. Depth I I Eastern Surface Seal Installed by air Work Done U Type of Pump H.P. State Work Done _ Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms V) Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK Cl Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line Z SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: 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 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-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 applican rgust call for all requir d inspections. Complete drawing on revers side. Nr .� Signed X t/ C c/ Title: U►-LL .6% Date:FOR DEPARTM T USE 9NLY 1 Application Accepted by A. vXA, Date Are, Pit or Grout Inspection byr or_ Date Final Inspection by Dave &v? ✓Z Additional Comments: " _Avr 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 CK RECEIVED 8Y ATE PERMIT'NO. INFO �1 . EH13-21(REV.iins) E1.2e t V �J w 9 C1 -�--� , C ) H t