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SAN J UIN COUNTY PUBLIC HEALTH AI ICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) VVV 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 comiliaice with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. i. Job Address E City GK 1_-. Lot Site/Acreage 3fe0, s. x,%3i Owner's Name . C-ff• � / E� Ir -�i Tn Address o �a CA Phone I"`owo 4 Contractor ty-_- __Address - License No. (:29794 Phone Jff3$--&S0 -• TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1.7 DESTRUCTION ❑ Out of Service Well ❑ b PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ �rt+�� OTHER Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK )jlA- SEWER LINES is DISPOSAL FLD. av A PROP. LINE FOUNDATION AGRICULTURE WELL NA OTHER WELL NA PITS/SUMPSNA4 INTENDED USE IV/A TYPE OF WELL A//A,PROBLEM AREA CONSTRUCTION SPECIFICATIONS C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationN� IA Dia. of Well Casing 1u l"1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 1�l,/F► Specifications N17� I I'1 Public ❑ Other ArDeita Depth of Grout Seal _ O-3G Fk•. Type of Grout-- I I irrigation ____Approx. Depth l I Eastern Surface Seal Installed byAr Repair Work Done N�� Type of Pump H.P. State Work Done_. Well Destruction ❑ Well Diameter Sealing Material8 Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION 1 I (No septic system permitted if public sewer is W/A available within 200 feet.) I Installation will serve: Residence °Commercisl— Other II 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: Welt Foundation Property Line T, LEACHING LINEN A ❑ No. 8 Length of lines Total length/size FILTER BED / ❑ Distance to nearest: Well Foundation Property Line 1 li SEEPAGE PITS 11 Depth Size Number SUMPS N/A LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1 hereby certify that 1 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 cartify 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." r The applicants must call for all squired inspections. Complete drawing on averse slide. ,(�Ct � -� Signed Title: rt.n Ch /�� r G.n a r J Date: i FOR DEPARTMENT USE ONLY Application Accepted by Date Area Pit or Grout Inspection by Date L,-Final Inspection by Data 1 Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2 , Stkn, CA 85201 INFO AMOUNT DUE AMOUNT REMITTED CASH E IVER BY DATE PERMIT'NO. . ENtY24 IREY.rinse 5�3 �.� •60 l ar{o r'f 2 .3 EH t4.m