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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES E, . ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 No wA l P O BOX2009, 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 Services. �/� A#ROY( Xy ob Address �, � �T /��Ty� City--�/�, � Lot Size/Acreage o x nOwner's Name rs'�p� `W�.9f,M' #_dA'e ddress �36fs 741�i��/y.� �T�/C Phon r? % a-l/ foeA Contractor C Address License No. �PhoneT PE OF WELL/PUMP: W WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Oervice Well ❑PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ itoring Well L7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL -ViFEbL PITS/SUMPS INTENDED USE ROBLEM AREA UCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Ma a of Well Excavation Dia. of Well Casing [7 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing''= ,- Specifications I'1 Public ) OtheF n Delta Depth of Grout Seal Type of Grout 1 1 Irrigation —Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done v Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION„VeNo septic system permitted if public sewer is ailable within 200 feet.) Installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms ` Character of soil to a depth of 3 feet: Water table depth �l3 SEPTIC TANK ❑ Type/Mfg Capacity-- No. Compartments Z PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ll No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 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 applicant t I forAl required inspections. Cgmplete drawing on reverse side. XSigned X Title: P 60/yie� Date: T OR DEPARTMENT USE ONLY Q Application Accepted by Date —` V�l`CL Area 4 Pit or Grout Inspection by Date Final Inspection ✓J Date , , 3 Additional Comments: - t 6 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. INFO CASH . EH13.24(REV.i/N5) 7y �"` . © 2-EH 14.2692,0 713,