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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, STOC%TON, CA 95201 PERMIT WIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application in hereby ssde to San Joaquin County for a permit to construct and/or Lnatell the work herein described. This aPPllcatlon is made in caalvllance with Sap Joaquin County Ordinance No. 549 and 16Q and the Rules and Regulations of San Joaquin County Public Health Bervfcee. Job Address IJ 17� 'Yl rl t/bi1� 11.C�. ,1/�C}ity�// (]/� Lot Size/Acreage S ne3 Owner's Nam 2Z Adsress _—I L� !V Vo,.,e A& Phone %-�22 9/ r f) Contract Address ( � 1RIE'% 76 7 i z f License No.3 z Y Z Z t- Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Cl DESTRUCTION ❑ Out of Service 4111 ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom E Manteos Die. of Well Excavation Dia. of Well Casing Ci Domeatm/Private 0 Gravel Pack O Tracy Type of Casing- Speclflcatwns I'1 Public Cl Other n Delta Depth o1 Grout Seat Type of Grout 1 1 4riflation __ Approx. Depth I I Eastern Surface Seal Installod by Repair Work Done J Type of Pump H.P. Slate Work Done _ Well Destruction ❑ Well Diameter Sealing Material L Depth Depth holler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I REPA1 ADDITION DESTRDCTIDN I I ENo septic system pMmined it public sewer is available within 200 feat,I Installation will serve: Residence� Commercial_ Other Number of living units: _.� Number edr character of sok to a depth of 3 het: Water table depth - SEPTIC TANK ❑ Type/Mfg Cspacity..46,00 No. Comportment$ 2— PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Wall Foundation Property Line AD LEACHING LINE ❑ No. L Length of fine, Total ongth/sire r FILTER BED ❑ Distance to iserset: Well Foundation Properly Lin. t it SEEPAGE PITS Depth S Sire Number SUMPS LI Distance to nearest: WeR Foundation fQy Property Line 5 DISPOSAL PONDS ❑ 1 l" an tangly tMt 1 have Prepared this acounttwn and that tne work vAN be done m accordance with San Joaquin county ordinances, ;Nle laws, and poo,and rpuotwns of the San Joaquin county Home owner or licensed agent's signature certifia the following: "I conity that in the Performance of the wort for which this permit is issued, I Shall not ee ploy any the following:m such rater as m become aublect to workman's compensation laws of California." Contractor's hiring m subcontracting signature wrap: " esrtdl'that in ins Performance of the work for which this permit is iuued, I shall emloy person,subject to workman's componsa tion avis of Califono." p The spoken can forr tw d wspactione. Compote drawing on reverse Signe, Title: _ 7`!'�j _'/i Date: t� FOR DEPARTMENT USE ONLY / /� r Applicnon Accepted by DaN( �/ 2 Arse z Pit or Inspection by DatB� Final Inspection by �j i lL Data AtleHionel Commas: Applicant - Return all copies to; San Joaquin County Public Health Services s 6451 romrenHealth Perini tServices Joaquin, 446 N San Joaqu lis, P O Box 2009. Stint, CA 96201 FEE AMOUNT DUE AMOUNT REMITTED CK INFO CASH RECEIVED BY DATE PERMIT-NO. EM t>,44Ary ,,,, �iv�� i 1l y-d� Sit ir.3$ L � ,23fz �.—�3S