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r SAN AQUIN COUNTY PUBLIC HEALTH AVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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 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 Se vices. Job AddresslCf City AJ 0L`� _ Lot Size/Acreage Owner's Name Address Phone _ Contractor Igno,11V Sp� Address � _ IVh 010 L— License N —Phone ..� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Fl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAR TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION ULTURE WELL OTHER WELL P1�S{�UMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR NS [� Industrial O Open Bottom ❑ Manteca Dia xcavation Dia. of Well Casing C.i Domestic/Private ❑ Gravel Pack O Tr Type of Casing_ Speci ons I'1 Public (1 Other f1 Delta Depth of Grout Seal Type of 'ons. I I Irrigation prox. Depth I I Eastern Surface Seal Installed by v Repair Work Do Type of Pump H.P. State Work Done Well Des uction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.) Installation will serve: Residence_ CommercialxOtherZr Number of living units: Number of bedrooms ee Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg ,�n2� cepacity as No. Compartments �1 PKG. TREATMENT PLT. ❑ Method ^^o7ff DD�i,sp��osal WI Distance to nearest: Well �� Foundation Property Line LEACHING LINE Ll No. & Length of lines oe Total length/size FILTER BED CI Distance to nearest: We Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS /�G 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 c th he performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Califor . The ap must call for al ^uir inions. Complete drawing on r er a side. . C , Signed X — Title: U/(%'�` 1 — Date.- .7,7,I ,. FOR DEPARTMENT USE ONLY Application Accepted by Date_ �Z Area V1 G Pit or Grout Inspection by Date Final Inspection by r Date Z 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 fto'E AMOUNT REMITTED CK yECEIVED BY ATE PERMIT'NO. EH 13-24 IREV.,in51r � l �?EH N.2G i ,� J ILS 1A c/l,�