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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 3'y/ 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 in hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This application 1e made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. �, _ / �7� ,y t Job Address C� Ll~{ Z5,eJziN�yr/" City_ Lot Size/Acreage p v �S r wner's NamestoeAddress Phone 1 7` — Address License No. Phone ✓✓✓ TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACE Cl DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REP IR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEW LINES - DISPOSAL FLD. PROP. LINE FOUNDATION AGRICUL RE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREMate N SPECIFICATIONS fl Industrial O Open Bottom O Mantecaavation Dia. of Well Casing Cl Domestic/Private ❑ Gravel Pack ❑ Tracy __ Specifications ` Il Public F1 Other fl Delta Seal Type of Grout I i t.,t;trunn _ - Approx. Depth I I Eastern ta by - Repair Work Done U Type of Pump N.P. ate Work Done _ Well Destruction 0 Well Diameter tae ing Material i Depth ,I Depth Filler Material i Depth PE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence Commercial_ Other Number of living units: Number of bedro mg Character of soil to a depth of 3 feet: a �- Water table depth S SEPTIC TANK O Type/Mfg ACZ 4F-aA1Z=k Capacity 09 evoo No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Wella;206b Foundation � _ Property Line '14C.)o :f-- LEACHING LINE Cl No, 6 Length of lines - .r Total length/size �� Z FILTER BED 0 Dfitance to nearest: Well n-2&p Foundation �� Property Line O 41o) SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ V I 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 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 must call 11 uired Ins one. Complete drawing on reverse side. Signed X Title: __ - - Date: Z Z� DEPARTMENT USE ONLY Application Accepted by Date r - Z Area Pit or Grout Inspection by Date Final Inspection by DatA�� 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATES PERMIT NO. . EH 1324IREV.Iix51 J 11 r'o EH 14le