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� � N SAN ,AQUIN COUNTY PUBLIC HEALTH IVICES ENVIRONMENTAL HEALTH DIVISIUA 445NSAN 420 OX 2009, STOCCKTON, CA PO 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 hereiP�Iatioof application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules an eJoaquin County Pubblic Health Services. �/�pJob Address 7" '�` � L r �a�n� City�oC-�- LQi1 Lot Size/Acr geOwner's Name 1llN (41g& P&0Pt'�"ddress q& �� R" Phone Contractor • f Address �� 'T f Ltd{_ License No.�7' 3 Phone �� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT F1 DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK 4 UA I- — SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMRS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI {JS l.C��% �a 1 r/ ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casin Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing e— Specifications I'1 for (1 Otter n Delta Depth of Grout Seal Type of Grout Ir gation Approx. Oe th 11 Eastern Surface Seal Installed by Re it Work Done U Type of Pump + IN r- H.P. 10 State Work Done _ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material & Depth 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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line d SEEPAGE PITS 11 Depth Size Number SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 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, 1 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 rvVst call for all req Tld inspections. Complete drawing on reverse side. Qr Signed Title: C'C_ / V - Date: o &a.", F MENT USE ONLY Application Accepted by �— Date (a—�� tea O Pit or Grout Inspection by Date Final Inspection by Data o 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 DILE AMOUNT REMITTED CK iiRECEIVED BY INFO CASH DATE PERMIT NO. EH13.24(REV.1/ 5) W� '�?< �Z EH 14-2e UI / `t'