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SAN ,AQUIN COUNTY PUBLIC HEALTH IVICES 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) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein descr bed. 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. t )(Job Address ! 0,;/, ��`r J �� City`:5)ir XJOA J Lot Size/Acreage XOwner's Name 41u3rGS L. !a N Address IVia Sit/4-) A✓e , tsS , ,C z phone 7�v( � ��41a,04ontraclorS ecA)J' ' ""e 7_70 Addressx License No. T� Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ .` SYSTEM REPAI OTHER ❑ Monitoring Well C� DISTANCE TO NEAREST: SEPTIC TANK SE LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL LL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM CONStRUrTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ eca Dia. of Well Exca alio= Dia. of Well Casing CI Domestic/Private ❑ Gravel Pack Tracy Type of Casing_ _ Specifications \_ 11 Public Ll Other-_ n Delta Depth of Grout Seal Type of Grout Q I I Irrigation _ Approx. Depth I I Eastern Surface Seal Installed by OBJ Repair Work Done ❑ Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material 6 Depth Depth Filler Material L Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is vailable within 200 feet.) l~ Installation will serve: Residence_ Commercial _ Other Number of living units: Number of booms Character of soil to s depth of 3 feet: A Water table depth SEPTIC TANK ❑ Type/Mfg No. Compartments PKG. TREATMENT PLT. ❑ Pe - Method of Disposal Distance to nearetj ork'JVfe 1 M4 �"�° t�� Wit Property Line yWf/ �. Int-I 0 k !I C L n�k LEACHING LINE Ll No. & Length of Ii Y �.f. �ed or 111rn��nl,Ja h/size y l ((f� FILTER BED ❑ Distance to nearest: Well IF �nProperty Line I.J10n SEEPAGE PITS 11 Depth Size _ Number SUMPS l.1 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 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 ust call for all req .red inspections. Complete drawing on reverse side. , � Title: L � L%Y Date: - _TMENT USE ONLY Application Accepted by AA_A.A� � � Date /— 1 ` Area t I Pit or Grout Inspection by Date Final Inspection by 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 DATE PERMIT NO. INFO CASH EH 13-24(REV. i x 5) D -7 E 7 t b t ♦ 1 / ( �C� q „/ EH 7�2E l