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SAN J'OAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIV 445 N SAN JOAQUIN$ PHONE (2 P O BOX 2009, STOCKTON, CA 9520 / PERMIT EXPIRES Z 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ' )QJ Address �` -d �V � J [ City �(�f'�ot Size/Acreage 0 Owner's Name ' t�[/�l CIO 8 LO A-' Address E � �� -L`Phone X-Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ,_ DESTRUCTION C1 Out of Service Well ❑ - PUMP INSTALLATION ❑ — SYSTEM REPAIR ❑ , OTHER ❑ Monitoring Well L7 DISTANCE TO NEAREST: SEPTIC'TA SEWER LINES &POSAL FLD. PROP. LINE FOUNDATION ~ ULTURE W OTHER VIIELO PITS/SUMPS 1 INTENDED USE TYPE OF WELL PROBLEM AR STRUCTION SPECIFICATIONS M Industrial ❑ Open Bottom ❑ M ca Dia, of a anon Dia. of Well Casing C1 Domestic/Private ❑ Gravel Pack Tracy Type of Casing_ Specifications I'l Public El Other n Delta Depth of Grout Seal Type of Grout 1 1 Irfigation �T A prox..Depth 1 ! Eastern Surface Seal Installed by Repair Work Done L1 Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter _ Sealing Material & Depth Depth Filler Zterial & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTIO YINo septic system permitted if public sewer is 'available within 200 feet.l Installation will serve: Residence_ Commercial_ Other Number of living units: Number of bedrooms Q Character of soil to a depth of 3 feel Water table depth SEPTIC TANK` ❑ T !Mfg g �. �� t Capacity No. Compartments Vpe r y PKG. TREATMENT PLT. ❑ Method of Disposal G 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 SEEPAGE PITS 11 Depth '` Size Number- SUMPS umberSUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 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- non taws of lifornls." . The appWant ant ust call for all requirein 7ptions, Complete drawing on reverse side. `X Signe Title: Date: ., FA-DEPARTMENT_ USE ONLY Application Accepted by Data Area Pit or Grout Inspection by - ate FinaPJnspecti by ,5%� Date Additional Comments: `,� / Ake -- 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 REMITTEDR RECEIVED By DATE PERMIT NO. INFO Lj 7 . EH 13•24IREV.IiKsi EH 14.2E 2N ✓✓✓