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SAN JOIN COUNTY PUBLIC HEALTH SE10ES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P 0 BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to San Joaquin County for a Permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin county Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. ` Job Address /Zyins./Gn 'l-zCity ✓ Lot Size/Acreage d / / "� • U 'GQ( Oy��l Addressr2�LM+t✓ C�+ b s(la i Phone �Ur w Z 772 Owner's Name �.G.-.• Contractor // ,y/tr i��/� Address �2✓ &3G, .[fir,Xf zr 6r r-icense Nd.-�S7.rd�B.J�Phone'G� 37y 3 ell TYPE OF WELL/PUMP: NE WELL -;g Ar" rJ WELL REPLACEMENT El DESTRUCTION Gat of ` MonitoringWell G PUMP INSTALLATION G SYSTEk? FFPAIA ❑ OTHER G �j w+/ JS OTHER DISTANCE TO NEAREST: SEPTIC TANK Z-- SEWER LINES "" - DISPOSAL FLD. PROP. LINE _ FOUNDATION AGRICULTURE WELL +N+ OTHER WELI-tt - "4''PITS/SUMPS _ INTENDED USE A101, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Z +/ G Industrial 00 ,pen .Bottom G Manteca Dia. of Well Excavation Dia. of Well Casing `rT' Type of Casing s,cl Y&I �` � Specifications -e2,5751 +—_ G Domestic/Private G Pack G Tracy 9 of Grout 1'1 Public 11 Other f i Della Depth of Grout Seal Type I I Irrigation jAPprox. Depth I I Eastern Surface Seal Installed by Repair Work Done G Type of Pump H.P. State Work Done _ Well Destruction ❑ Well Diameter Sealing Material & Depth Depth Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I availsOPelw shin system rented it public saw is Installation will some: Residence — Commercial_ Other 1 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 G No. & Length of lines Total length/size 1 FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I I Depth Size Number , SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS G 1 hereby certify that I have prepared this applicanon 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 n 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 or all required inspections. Complete drawing on reverse reeverse side. Signed X Title: , lei✓ Edi '. �'Py�Lri/ Date;- / ?�/�/�— 9 FOR DEPARTMENT USE ONLY q �! Application Accepted by G Date Area Pit or Grout Inspection by Date / Final Inspection by Date �•� 1 ' Additional Comments: s Applicant - Return all copies to: San Joaquin County Public Health Services D Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 cD FEE gMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT' O. •7 Q 9 EH 1324 IRW.11"s) �9 Q 9/ gOU �!/ �� EH 147a