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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. 5119 and 1662 and the Rules and Regulations of San Joaquin County Public Health Services. � o ;! w• ,,nr�+s7 //�� ,�l M � 1 p rs- 230_l 3 Job�'Address _A1/� �UCf2�ifC�[7r� Ni M1,L �Q �/� City �o r Lot Size/Acreage Owner's Name _(�I E 1 y � Address Phone NC-AJ0 4E� T Q ContractorNowAddress l_`S:?Z License h �PhoneQ Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service Well ❑ O PUMP INSTALLATION ❑ SYSTEM REPAIR TC OTHER C1 Monitoring Well C7 DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS F1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing r.] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications PoPublic 1-1 Other it Delta Depth of Grout Seal Type of Grout I I Irrigation — Approx, Depth I I Eastern Surface Seal Installed by �j Repair Work Done L�Type of Pump IP-+ 1 �►H.P. �� State Work Done Well Destruction ❑ Well Diameter Sealing Material & Depth 0'r—�/d, Depth Filler Material i Depth /Z /C TYPE OF SEPTIC WORK; NEW INSTALLATION t I REPAMIADDITiON I I DESTRUCTION I I (No septic system permitted if public sewer is 1( �` available within 200 feet.) 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 SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size .� FILTER BED ❑ Distance to nearest; Well Foundation Property Line a �+ SEEPAGE PITS 11 Depth Size Number \� SUMPS it 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 ,JCP 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 must call for all required inspections. C mplete drawing on rer side Signed X Oteze Title: Date: r OR DEPONLY �Q Application Accepted by ,sept T Date T,? 1 Z Area Pit or Grout inspection by Date Final Inspection by Date Additional Comments: rn Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 2009, 945 N San Joaquin, P O Box 2009, Stkn, GA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK If RECEIVED BY DATE PERMITNO, EH 13.21(REV.I)K 51 t✓ �� EH 11-ZE I s � v I