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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES c ENVIRONMENTAL HEALTH DIVISION f 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I. 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 1$62 and the Rules and Regulations of San Joaquin County Public QHealth Services. &)Job Address __ '7 o /&ANd-r 9b City Lab / Lot Size/Acreage Owner's Name JJfA SCJEF Address —/1S_9y0 E JRe}uV V J A) Phone Contractor Address License No. Phone TYPE OF WELL/PUMP, NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR L7 OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS \ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS }+\ F) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing'` Cl Domestic/Private Ll Gravel Pack Ll Tracy Type of Casing_ Specifications 11 Public is Other fl Delta Depth of Grout Seal Type of Grout I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth y t, TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION DESTRUCTION I I tNo septic system permitted if public sewer is ` 1 available within 200 feet.l Installation will serve: Residence Commercial _ Other Number of living units: _J— Number of bedrooms 3_ _ f Character of soil to a depth of 3 feet: - __ Water table depth SEPTIC TANK. Q,--Type/Mfg Capacity No.. Compartments PKG. TREATMENT PLT. ❑ Metfiod of Disposal Distance to nearest: Well Foundation Property Lire ` LEACHING LINT No. & Length of lines Total length/size FILTER BED 0 Distance to nearest: Well/_DJ2_._,.-, Foundation Property Line ' SEEPAGE PITS Depth TSize Number f' SUMPS LI Distance to nearest: Well Foundation Property One f . DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work wilt 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.",Eontractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is ist:ued, I shall4mploy persons subject to workman's compensa- tion laws of California." The plicant must call for all requ'ed in ctions. Complete drawing on reverse side. - It. 1r SigneJJ0 Title: Date: w FOR DEPARTMENT USE ONLY Application Accepted by Date Area Q y Pit or Grout Inspection by Date Final Inspection b Date r k Additional Comments: A" Applicant - Return all copies to: San Joaquin County Public Health Services ! �I Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 INFO f AMO NT DUE AMOUNT REMITTED 4 GK - RECEIVED BY /y DATE PERMIT'N0. . Eli 13-20(REV.f iw st LJ + 1 r / �` ` '/ EH 11.26 I/ _ /