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� I _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 1 445 N SAN JOAQUIN, PHONE (209)468-3420 pI P 0 BOX 2009, STOCKTON, CA 95201 I! PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i (Complete in Triplicate) I 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 Healt/h� Services. , Job Address /�y��/ 30 f\/ r� City E. G[J�/ Lot Size/Acreage ii I ' ^ r Owner's Name /C� •Etrr!L L Address Phone I Contractor z5,eZL Address / �A7�yT�fs(� License No/?� Phone TYPE OF WELL/PUMP: i, i' NEW WELL ❑ `, WELL REPLACEMENT 171 DESTRUCTION CI Out of Service well ❑ 1`'i Monitors well E PUMP INSTALLATIONl SYSTEM REPAIR ❑ OTHER ❑ O DISTANCE TO NEAREST: SEPTIDTANK, __ SEWER LINES DISPOSAL FLD, PROP. LINE ` FOUNDATION 1 AGRICULTURE WELL OTHER'WELL PITS/SUMPS 1 INTENDED USE TYPE OF WELL- PROBLEM AREA _ CONSTRUCTION SPECIFICATIONS 11 Industrial ti ❑ Open Bottom ❑ Yanteca ,,Dia. of Well Excavaiion Dia. of Well Casing CI Domestic/Private 0 .Gravel Pack ❑ Tracyl`_� Type of Casing_ T Specifications I'i Public 6 _ 1-1 Other fl Delta Depth of Grout Seal Type of Grout 11 Irrigation __ Approx:1bepth 1 1 Eastern Surface Seal Installed by I Repair Woik Done' Er Type of-Pump - ` H. . State Work Hone_ Well Destruction ❑ We0biameter Sealing Material b Depth t Dep . Filler Material 6 Depth I TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION DESTRUCTION) WO septic system permitted if public sewer is I I IInf available within 200 feet,I installation will serve: Residence commercial— Other Number bf living units: _4 Number of bedrooms __X V Character of soil to a depth 04 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg L- Capacity/& No. Compartments CP— PKG. TREATMENT PLT.❑ Method of Disposal t �t� ! ca- Distance to nearest: Well Foundation � Property Line ` II _ LEACHING LINE El No. S Length of lines �' Total Iength/size FILTER BED C1 Distance to nearest. Well Foundation ��Property Line 4 SEEPAGE PITS Depth Y Site Number SUMPS LI Distance to nearest: 1 Welles Foundation F_/- Property Line DISPOSAL-PONDS C) 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 SanJoaquin County Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whiclti this permit is issued, I shall not .employ anyFperson in such manner as to become subject to workman's compensation laws of California." Contractor's hiring,'or sub-contractinisignature certifies ths'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.'.'... II l The applicant 'roust call for I r 'quired d ins ctions. Complete drawing on reverse side. q. Signed II Title: EEE Date: I� F DEP TME USE ONLY Application,Accepted by Date/�� u � ea or Grout inspection by Date Final Inspection b Date�a �. .Additional Comments: � 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 i FEE INFO* Y -,..:R�E,C,:.E.,N. E.�D.i9.�.Y:.._..-..,.._..D-_./arA _TE- -PERMIT',NO: -- EH -�,- - t42e II 4