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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)46$-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. 5:4g and 1862 and the Rules Regulations of San ' Joaquin County Public Health Services. NCS. S7a + " XJob Address �� ' � •" ity Got Size/Acreage 77Y AV& 40 r Ill® Dr-Dg'ZA Q, Z-Address �� r g `� Phone Owner's Name A�� aZ067 sour/ oui✓e 04✓6. -� >e_Contractor 564 F� S0AiS_ Address _';7Z> A1 t 4 ' o"il�' License No. �' � Phone dsl3 TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT F7 DESTRUCTION C1 Out of SerriCe Well Well ❑ ' PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ ng DISTANCE TO NEAREST: SEPTIC TANK SEWER L ES OSAL FLD. PROP. LINE FOUNDATION AGRICULT E WEL OTHER WELL-,PITS!SUMPS INTENDED USE TYPE OF WELL PROBLEM ARE TRUCTION SPECIFICATIONS O C1 Industrial ❑ Open Bottom ❑ Ma Dia. of Excavation_ Dia, of Well Casing N Domestic/Private 0 Gravel Pack racy Type of Casing_ Specifications I'1 Public is Other r n Delta Depth of Grout Seal Type of Grout I I tnigation �_ prox. '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 Materiel A Depth Depth ' .I Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION I I DESTRUCTION i o septic system permitted it public sewer is vailable within 200 feet.1 Installation will serve:"Reside ce '"� Commerciaf�_ Other ZK i Number of living units: _4Z Number of bedrooms 421, Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK 'fes', CIType/Mfg Capacity No. Compartments R� f PKG. TREATMENT PLT. ❑ 1 + Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Ell! No. & Length of lines Total length/size FILTER BED n s Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS y LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑-, . f I hereby cenify 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 Sen 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 Ibecome 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 Califomla." f The applicant ust call far all quired inspections;Complete drawing on re se side. Signed X f Title: Date: .9 meg-gY OR DEPARTMENT USE ONLY Application Accepted by AL. L iR MQ Aft Date AreaU Pit or Grout Inspection by Date Final Inspection by Date N /r Additional Comments: 4 Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services k 445 N San Joaquin, P 0 Box 2009, Stkn, GA 95201 FEE AMOUNT DUE k AMOUNT REMITTED ASHCEiVEO BY D TE PERM17'N0. INFO -1 I EH 13-24IREV.tense 51 1 I EH 11.20 V 11 ,�