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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 apd Regulations of San 4, Joaquin County Public Health Services. � +� " � 3 d �` S 4 19V City e Lot Size/Acreage Job Address _--ter-- -- Owner's Name �{� .r01�Address / U �� yN _ Phone �� Conhactor _4177 Address b wr /hf /S License No. Phone TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACE ENT Cl DESTRUCTION ❑ Out of servicewell ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR e-' OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation - Dia. of Well Casing 1 1 Domestic/Private ❑ Gravel Pack 4 -T-racy Type of Casing_ Specifications V1 Public 1-1 Other Fl Delta Depth of Grout Seal Type of Grout I I Irrigation Approx. Depth l I Eastern Surface Seal Installed by r t- Repair Work Done €�Type of Pump (a b 07 H.P. _ Ste Work Done nr�0 Well Destruction ❑ Well Diameter Sealing Material i Depth Depth 677-00 Filler Material i Depth,,. TYPE OF SEPTIC WORK; NEW INSTALLATION I i REPAIR/ADDITION i I DESTR TION[ 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 �* " A 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 PAYMENT LEACHING LINE D No. Length of lines Total length/size RMEIVED FILTER BED ❑ Distance to nearest: Weil Foundation Property Li,0 R-1992 SEEPAGE PITS I I Depth Size Number ICES �� SUMPS LI Distance to nearest:' Well Foundation Pro �R�j Tat NEA�YH SION 7 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 compensalion taws 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 m call for regd inspections. Complete drawing on reverse side. Signed X�.. f If1.O - . ---- Title: .4 Date: r� FOR DEPARTMENT USE ONLY / 7 ,_ 0?/16 6.a Application Accepted by Date Area Pit or Grout Inspection by Date Final Inspection by Date z7 � 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 DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'N0. INFO . EH 13.24 IREV. EH 4-2e �� wr