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SAN _)AQUIN COUNTY PUBLIC HEALTH 'RVICES ENVIRONMENTAL HEALTH DIVIS� i 44541 PNOOX S JOAQUIN, PHONE 420 22009, STOCKTON, CA l c �� I a PERMIT EXPIRES 1 YEAR FROM DATE ISSUED W (Complete in Triplicate) Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herei bed. is application is made in compliance with San Joaquin County Ordinance No. 549 and 1662 and the Rules an egulatio of Sa Joaquin County Public/Health Services. �4 Job Address / 7' 7`�` CLZj( 1�7(�C% 4�J City�V` O Lot Size/Acr ge 0 4 Owner's Name�/I h 67 (7 Win l'.-cf PhA-) 1 T 1F_Address 61& y R Phone Contractor f�Q License TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR' OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 4 011 SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI NS Luoll 77 I d I f_l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin l DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing�Ce� Specifications I'1 lblic I 1 Other (l Delta Depth of Grout Seal Type of Grout Ir gation 3CJt� Approx. De th I I I Eastern Surface Seal Installed by 1 Re it Work Done 13 Type of Pump y th H.P. -�..� State Work Done _ Well Destruction O Well Diameter Sealing Material i Depth Depth Filler Material i Depth r TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No 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 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS ( I Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS O 1 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 94pst call for all requir d inspections. Complete drawing on reverse side. Signed Title: Date: F MENT USE ONLY Application Accepted by C7", L— ��•rr�p Date Kra o Pit or Grout Inspection by Date Final Inspection by - � Date,�P a Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE AMOUNT REMITTED CASH CK f RECEIVED BY DATE PERMIT NO. '•o ' • EN 11-24 IREV.r i n s) W� ^� el._ � / � C-0 ' n EH 1436 LJ >�� {��L} ,,� 7/.