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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 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 San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health services. e �' Job Address �G S ! � City r�Ia v/ Lot Size/Acreage Owner's Name -eI►r_4e hr .S est l4 �✓13 r�C�Phone iF&6�10d �9eq w Contractor [[ Address ' � S Lens rvo. &_,3&L_&_ Phone "X116 IiI TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C7 DESTRUCTION 0 Cut of Service Well ❑ 4 PUMP INSTALLATION SYSTEM REPAIR i=] OTHER ❑ Monitoring Well "%--.DISTANCE-TO NEAREST:-,SEPTIC TANKz SEWER LINES DISPOSAL FLD. PROP. LINE_ _ - = - � ... : FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS�� INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack MIT racy Type of Casing_ Specifications I I') Public C7 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation _Approx, Depth l-I Eastern Sjodace Seal Installed by �} Repair.Work Done ❑ Type of Pump �Gf,b H.P. State Work Done ,fie�CV� W 1 i rs .7-✓ Well Destruction ❑ Well Diameter IO d� Sealing Material 8 Depth co Depth Filler Material 6 Depth _ TYPE OF SEPTIC WORK; NEW INSTALLATION I I ' REPAIR/ADDITION l I DESTRUCTION I I INo septic system permitted if public sewer is �+ available within 200 feet.) i Installation will serve: ' Residence — Commercial_ Other Number of living units: Number of bedrooms PAYMENTCharacter of soil to a depth of 3 feet: Wa � SEPTIC TANK ❑ Type/Mfg Capacity No.�oZa nt PKG. TREATMENT PLT. 0 Meihfdtf bf�i os. Distance to nearest: Well FoundationPrope$��n K!'y HEALTH SERVW LEACHING LINE Cl No. & Length of lines Total Ieg4N)8NMLNIALHLFI UIVIZ1 FILTER BED C] Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number SUMPS LI Distance to nearest_ Well on Property Line r� . -R-- �- - - - --- DISPOSAL PONDS ❑ _-. 7 Foundati_ - __4_ _.� _f_1 14 t 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 i 1! 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 applicanLsrgat call foF all regypred inspections. Complete drawing on reverse side. Signed Title: P Date: F DEPA13TMENT IJ4 ONLY Application Accepted by Date 2� Area f Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: I 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 AMOUNT DUE AMOUNTREMITTED RECEIVED BY DATE PERMl7'NO. INFO CA + EH 13-24tREY.iin EH 14411 yi d:9O