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R s 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 EXPIRES 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 Ban Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public 2-3 !2Health Services. �f,2,, e Job Address _ k Er Mu ^ Z,6City2kdQW Lot Size/Acreage Owner's Name V1 18 ignd_FC. lZrZ Address AK ve _^ Phone `0 Contractor Address�TdC ' �lf. icense No,:Z Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Ci Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR L) OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ' A2omestic/Private 0 Gravel Pack El Tracy Type of Casing_ Specifications tj\ I'l Public 1-1 Other Cl Delta Depth of Grout Seal Type of Grout I I Irrigation ____..Approx, Depth l I Eastern Surf ee 'Se'al�In7stalled by Repair Work Done L7 Type of Pump H.P, � State Work Done t Well Destruction CJ Well Diameter Sealing Material & Depth Depth �N Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION ( I DESTRUCTION l I lNo septic system permitted if public sewer is available within 200 lest.) Installation will serve: Residence Commercial — Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth x SEPTIC TANK. 0 Type/Mfg Capacity --' No. Compartments PKG. TREATMENT PLT. El Method of Disposal i Distance to nearest: Well Foundation Property Line LEACH ING_LINE,_ 0- No. & Length of lines„ _ Total length/size T - FILTER BED 0 Distance to nearest. Well Foundation Property Line � SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS Cl 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 r 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 wsL4,all for all equired inspections..qomplete drawing an rse s' e. N J _ Signed X Title: Date: 7— _(_3_.� - ..` .._I FOR DEPARTMENT USE ONLY Application Accepted by Date Zr Area Pit or Grout Inspection by Date Final Inspection by Date a Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environments) Health Permit/Services 2 445 N San Joaquin, P O Box 2009, Stkn, GA 95201 FEE AMOUNT DUE AMOUNT REMITTED I CK 9 RECEIVED 8Y DATA: PERM17'NO. INFO CASH . EN 13-24 IREV. x S! EK 14.20