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" O'D APPL I CATION SAN JOAQUIN COUNTY PUBLIC HEALTH SER1qCES ENVIRONMENTAL HEALTH D I V I S I O AJ�}0# 445 N SAN JOAQUIN, PHONE (209)468 3 2" P 0 BOX 2009, STOCKTON, CA 952)]F-AC # PERMIT EXPIRES 1 YEAR FROM DATE I SSU # ((-YA� ., SC�4001L S'7` (Complete in Triplicate) Application is hereby made,to Ban Joaquin County for a permit to construct and/or install the work herein described. This application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I Job Address C 600 L St City Lot Size/Acreage r C'l�Ce-s /J�Lc3t v-'1 y9— (04071 Owner's Name �� r �� Address � /V,t ��L Phone Contractor EN � 51 /�C Addres _ _.V1.?Z- a S sa3 �7'f �rnca License No. Phone TYPE OF WELL/PUMP: T NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION t of Service Well Lj W i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER Monitoring well f DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 4 r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation Dia. of Weil Casing C7 Domestic/Private Ll Gravel Pack Ll Tracy Type of Casing_. Specifications Il Public i-1 Other Cl Delta Depth of Grout Seal Type of Grout f i I Irrigation —Approx.iDepth I I Eastern Surface Saul Installed by Repair Work Done 0 Type of Pump H.P. _ State Work Done _ Well,Destruction x7 Well opmeteI 'r Sealing Material i Depth >� �p Filler Material i Depth �w kj TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is �{�] available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Numb ier of bedrooms Q Character of soil to a depth of 3 feet: j Water table depth SEPTIC TANK 0 Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance,t nearest: Well Foundation Property Line PAYMENT LEACHING LINE Cl No. & Len'th of lines s w , 9 Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 994 AIV JOAQUIN COUNT SEEPAGE PITS 11 Depth Sire Number PUBLI ES TAL HEALTH pl ISIO� SUMPS Ll Distance to nearest: Wel Foundation Property Line DISPOSAL PONDS ❑ { 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 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: "1 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 applica m all for all r d inspection omplate drawing on reverse side. Signed Title: Date: - FOR DEPARTMENT USE ONLY s Application Accepted by Lc_-, Date1 f AreaO�1 Pit or Grout Inspection Date Final Inspection by Data-7& rl Additional Comments: Applicants - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services H 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FFEEAMOUNT DUE � AMOUNT REMITTED RECEIVED BY SH DATE PERMIT'NO. EH 13-24 iREV,i i n SrEH 14.26 11// IIVVV ,1,JV