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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES C1N«1C 4 ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 f T 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. 51+9 and 1862 and the Rules and Regulations of San Joaquin CountyPublic Health Services. )5-ON, Job Address + y kQ Ifu City of Size/Acreage Owner's Name 7 r t&y!/"`n � de(,p- Address 6_4> Q CAA 1 - - Phone �?b k ! A i ' icense No _� 4- Contractor � ress S L ,� �� hone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Nell 0 �5 PUMP INSTALLATION fa SYSTEM REPAIR C7� OTHER p ' Monitoring Well 0 DISTANCE TO NEAREST: TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUND N AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CON UCTION SPECIFICATIONS n Industrial ❑ Open Bottom nteca D' of Well Excavation Dia. of Well Casing El Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing- Specifications •` I'I Public f:l Other n Delta h of Grout Seal Type of Grout I I Irrigation _Approx. Depth l I East Surface a tailed by Repair Work Done 0 Type of Pump H.P. tate Work Done Well Destruction D Well Diameter Sealing Material E Depth Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION ( I REPAIRIADDITION I I DESTRUCTION K INo septic system permitted it public sewer is ` available within 200 feet.) r] Installation will serve: Residence— Commercial T Other O Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK. ❑ 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 [11 Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Cl Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 oenifies 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 app)ica t call for all require inspections. Complete drawing on reverse side. _ J 24 �ignad � ." Title: -DE-C.(34 FOR DEPARTMENT USE ONLY Application Accepted by :. ®ad—A E! J E Date Area -2 1 - Pit or Grout Inspection pownX Date Final Inspection by Date l� Additional Comments: GT d�7/�+f� -1rc tK �I VZ9- 11I"&AA&1,(,4 �1rJ�s�t �s►k- /`�"r� 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 INFO AMOU/NTT DUE AMOUNT REMITTED CASH �yRREECEIVED BY /Df�ATE PERMIT'NO. . EH 13. 41FIEV.1/xb) .�� + V d ®� C/� iP�/ SOL 3 'IDEH 14.2E