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a SAA _ i?AQUIN COUNTY PUBLIC HEALTH ERVICE S ENVIRONMENTAL HEALTH D I V I S i 445 N SAN JOAQUIN, PHONE (209 P 0 BO%'2009, STOCKTON PERMIT EXP S ED (Co lets zn ilaki Application is hereby made,to San Joaquin County for a permit to construct and/or install the vork herein described. This j application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Ruleet&nd Regulations of San 1 Joaquin County Public Health Services. !! *Job Address Boo City G1' Lot Size/Acreage 1 I G1G S� Owner's Name t� Address�.' Phone !. ri Contraclor ILI, Address e& License No. 3TS Phone -1 TYPE OF WELL/PUMP: NEVWELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 1010 SEWER LINES DISPOSAL FLD. 04 PROP. LINE FOUNDATION AGRICULTURE WELL BO OTHER WELL 7660 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I 4« i C7 Industrial C3Open Bottom ❑ Manteca Dia. of Well Excavation r` Dia. of Well Casing ' Ca Domestic/Private l$d'Gravel Pack ❑xrascyit Type of Casing- L- — Specifications 9 i"1 Public [-I Other i I Delta Depth of Grout Seal Sy"OfType of Grout .fs i I irrigation ____Approx. Depth t I Eastern Surface Seai Installed by 'j Repair Work Done U Type of Pump H.P. State Work Dona {' Well Destruction ❑ Well Diameter Sealing Material & Depth 0 i m Filler Material 6 Depth Depth Cj TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDiTION I I DESTRUCTION I I lNo septic system permitted if public sewer is available within 200 leet.l Installation wildserve: 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 tine LEACHING LINE I=1 No. & Length of lines Total length/size FILTER $ED n Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number SUMPS LI 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 shell 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 mu call for all req ed insPections. Complete drawing on/reverse side. Signed X Title: '454 a. 1, ,f Date: �Tjll Ssz-66 SA .�it�v sdrm-, 40 ( Y�� A FOR DEPARTMENT USE ONLY C Application Accepted by Hate Li�, Area Pit or Grout Inspection by Date Data Additional Comments: Applicant - Return3all copies to: San Joaquin County Public Health Services Environmental Health Permit/S ces / O 445 N San Joaquin, P O Box 2 9, tkn, CA 95201 vvv FEE AMOUNT DUE AMOUNT REMITTED C .J IR I ED BY DATE PERMIT'NO, INFO //,rr . EHt3-24{AEV.riM51r`4� @o C/' ,�0 �fJ i0`7y "!2'/� EH 14-20 VV