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SAN ,AQUIN COUNTY PUBLIC HEALTH _ _RVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 Waw r� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ;;.L- (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein descr bed. 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.. 4 l )(Job Address �'It7_& ' ' -- Cityy�m"" hot Size/Acreage 1 ' 'po ` 7a Z � tiexOwner's Name Address � �Ontraclar �a f r Lii77y� Address�� license No.V&IIQ 1V Phone 's TYPE OF Wf:LL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION 0 Out of Service Well ❑ PUMP INSTALLATION ❑. SYSTEMREPAI OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SE LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM CONS TION SPECIFICATIONS C7 Industrial ❑ Open Bottom ❑ eco Dia. of Well Exca at,Qn_ - Dia. of Well Casing Cl Domestic/Private Cl Graves Pack Tracy Type of Casing_ Specifications _ Il Public C] Other n Delta Depth of Grout Seal Type of Grout I I Irrigation —Approx. Depth 11 Eastern Surface Seat Installed by Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIOfNo septic system permitted if public sewer is ailable within 200 feet.) installation will serve: Residence— Commercial_ Other Number of living units: Number of Character of soil to a depth of 3 feet: '' A ii Water table depth SEPTIC TANK ❑ Typo/Mfg TNo. Compartments PKG. TREATMENT PLT. ❑ Fermi Method of Disposal Distance to neareii Weti��/e m p{f Wlt roperty Line WOrk N.00� .4...� !!C �- --- LEACHING LINE ❑ No. & Length of liff f lgfedIngth/size -- FILTER BED n Distance to nearest: Well�1�jfF41 l �j Property Line JIM SEEPAGE PITS [ I Depth Size Number SUMPS i Distance to nearest: Well 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: "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 applicant giust call f✓o all req iced insp�ec�tio�nsn. Complete drawing on reverse side. /i l. l�Ocam(/iw r- Signed Title: Date: TMENT USE ONLY ' Q Application Accepted by .w �, ]Date f— `Q ` Z__ Area oil Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: u� � -amu.f S�-�O` l Ga ` [ � � nl 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 CASH CK I REC/EEIV—ED BY DATE{ PERmi-i . . EH 13-26iREV.iinsi D -7 E-D eft 0 9 / 1 7 9 l� 9Z� EH 14-26