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SAN .IYI.QUIN COUNTY PUBLIC HEALTH S& ICES .. ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 I 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 theGvork herein described. This application is made in compliance with San Josquin,.County Ordinance 6o. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. .i, `e- city, C Lot Size/Acreage Jab Address Address 1J Phone 10 11C Owner's Name .Ztit Contractor Address CQ1, r LiCense No. TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION r0 Out of Service Well 0 PUMP INSTALLATION ❑ SYSTEM REPAIR ^, OTHER �f Monitoring well DISTANCE TO NEAREST: SEPTIC TANK >>1e4•,t SEWER LINES Z100' .._ DISPOSAL `� EIPROP. LINE�t�fi FOUNDATION `� AGRICULTURE WELL}{ OTiiER bvELL *PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 2r1 Cl Industrial ❑ K:4Open Bottom ❑ Manteca Dia. of Well Excavation_ '' Dia. of Well Casing_ _ 1-1 Domestic/Private R Gravel Pack 0 Iracy Type of Casing Specifications I't Public Cl Other 11 Delta Depth of Grout Seat Type of Grout I i IrriE7ation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done 0 Type of Pump �.^ H.P. State ark P na ~ Well Destruction ❑ Well Diameter Sealing Material & Depth �- Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADOITION ! I DESTRUCTION I I (No septic system permitted if public sewer is available within 200 feet) Installation will serve: Residence— Commercial_ Other Number of living units: Number of bedrooms V1 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 P� LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED 0 Distance to nearesti Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS Lt 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 shalt 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 appfii:7 st call for all re5,uired inspections. Complete drawing on rave(so side. Signed Title: + • _ __ Date: FOR DEPARTMENT USE ONLY s Application Accepted by �' ""-_ is Date - Arear L Pit or Grout Inspection by ��'�^-� - 0�'�' �j F� Final lnspectionrby_,_.� Data Additional Comments: <, Kd 3 /4: : S_• - Applicant - Return all pies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 CK FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. K INFO F, . EH 1�•J41REV.tiRel �r fx' � '� � !'t�r: LTi"' �U�� -��C EH 14.16 `J