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SAN QUIN COUNTY PUBLIC HEALTH VICES 'ENVIRONMENTAL HEALTH D I V I S I OFi 445 N SAN JOAQUIN PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �r^/ �� P �i;�/�`j! (Complete in Triplicate) / Application is hereby trade to San Joaquin County for a permit to construct and/or install the work herein desbed. This application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rulea`and Regulations of San Joaquin County Public Health Services. Job Address City Lot Size/Acreage Owner's Name L �� Address ZS �<<141 LLIAI—C Cx A6 Phone u� Q Contractor Qf-Su•� �� '��1t5 Address DiL' �v` S ` ' License No.C1Z9�� Phone TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT n DESTRUCTION ❑ Out of Service well O PUMP INSTALLATION_0 SYSTEM REPAIR C10THER i3� �M°„i or�cNell oDISTANCE TO NEAREST: SEPTIC TANK '> U; SEWER LINES >Sr' DISPOSAL FLO. '100 PROP. LINE FOUNDATION 2 3t AGRICULTURE WELLSSC OTHER WELL 2i5 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial O Open Bottom O Manteca Dia. of Well Excavation Dia. of Well Casing EI Domestic/Private Cl Gravel Pack O Tracy Type of Casing_ Specifications t'1 Public Y OtherS�Ls)ct„ 1%Delta Depth of Grout Seal 10 Type of Gr ut 11 Irrigation jL1 ,Approx. Depth I I Eastern Surface Soul Installed by Ql,�V wu�1�-5I�R�S Repair Work Done U Type of Pump H.P. State Work Done Well Destruction O Well Diameter Sealing Material is Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted it 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 ❑ No. & Length of lines Total length/size FILTER BED O Distance to nearest: Well Foundation Property Lina 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 shall not employ any person in such manner as to become subject to workman's compensation laws of California.” Contractor's hiring or subcontracting 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 applican ist call for 1 requir inspections. Complete drawing on reverse_ side._ \ 11 Signed X Title: �C'h:t4.tl� ' "`�"'t��. Date: y OR DEPARTMENT USE ONLY 2�. f Application Accepted by Date lO�� Area `J J Pit or Grout Inspection by Date Final Inspection by Date 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 if RECEIVED BY DATER PERMIIjT NO. . EH 13.24 IREV.I i n S) 1b.2.: 13 �' 1. EH 14-M `✓✓