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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT E%PIRES 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. Job Address 1i fi� City �� t Size/Acreage E � �q y � r Owner's Nam,.P/9,4 �X.SC O (�, Cv" Address �d� Phone Contractor Address License No, Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT l:.) DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTAQLATi ❑ SYSTEM REP R ❑ OTHER C Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION. AGRiCULT WELL OTHER WELL PITS/SUMPS .� INTENDED USE TYPE OF WELL PRO E I AREA CONSTRUCTION SPECIFICATIONS D Industrial ❑ Open Bottom ❑ Mant a Dia. of Welt Excavation Dia. of Well Casing C"1 Domestic/Private ❑ Gravel Pack x 0 Tracy Type of Casing_ Specifications 0 i'i Public Cl Other,.-' A� fl Delta of Grout Seat Type of Grout I I irrigation pprox. Depth ( I Eastern Surface Seal n ailed by Repair Work Done L3 Type of Pump i H.P. State Work Done — Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADD{TION I 1 DESTRUCTION iNo septic system permitted it public sewer is -available within 200 feet.) Installation will serve: Residence T Commercial„-, Other Number of living units: Number)of bedrooms Character of sail to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT,G7 .1 Method•of,Disposal Distance toearest: Well Foundation Property Liner r 4F� LEACHING LINE Cl No. & Length of lines Total length/size a } FILTER BED ❑ Distance to nearest: Well Foundation - Property Line i SEEPAGE PITS 11 Depth Size Nu�nber SUMPS Ll Distance to risarest: Well Foundation Property Line' DISPOSAL PONDS ❑ t :I 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 R 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 applican call for all required inspections Complete drawingo se side. f Signed X Title: i R D 1RTMENT USE ONLY z �t Application Accepted by Date " `� Area Pit or Grout Inspection bybyy� Date Final Inspection bDate I 1� , Additional Comments:"�" 7a-,:2,3 e 4 _".V—- — 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 AMOUNT DUE AMOUNT REMITTED CK 4 CASH RECEIVED BY DATE EPERMIT'NO.tEH 13-24 IREV.t n sl 999