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SANQUIN COUNTY PUBLIC HEALTH VICES �IRONMENTAL HEALTH DIVISIO'e 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDFly(Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the ,it erein 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. 1� ,1' {^Job Address gSlOa �R N n e� r) 6/T' Q—/ City//,a 0 _T---�i Lot Size/Acreage 1 Owner's Name 114 R V/ems �N JeSrM C&e7. g7� F�'"� ' Phone 8$� Conhaclor V1��h w Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT R DESTRUCTIONt of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER -IZMonitoring W 1 gS�4 Carly C� r DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bomom ❑ Manteca Dia. of Wefl Excavation Dia. o1 Well Casing C.1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications f'1 1'I Public f 1 Other Il Delta Depth of Grout Seal Type of Grout Q I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump H.P. State Work Done. Well Destruction ❑ Well Diameter Sealing Material i Depth /YI Depth Filler Material a Depth \•' t TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I ) INo septic system permitted if public sewer is 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 fest: Water table depth SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method o1 Disposal Distance to nearest: Well Foundation Property Line r LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS II Depth Size Number SUMPS 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 rubs and regulations of the San Joaquin County Home owner or licensed agent's signature certifies the following: "1 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 subcontracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- tion taws of California." rs-9ma pplica(r}��must call for allregqad iiriisP9ytions. Complete drawing onnrrev_ersseee si�Jde,d fc/s7' L1u�Llt� _ Title: )?xflsl�li Date: (\v`J' 1. / F R DEPARTMENT USE ONLY _ Application Accepted by O a ^^� as Date C L7� 6 Area �+ Pit or Grout Inspection by Date Final Inspection bi�t Q � Date Additional Comments: 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 AMOUNT REMITTED CK RECEIVED By DA PERMIT'NO. INFO ,/� . EH ti{r4 IaEV.vwal r EH tb]a - //��