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SANUIN COUNTY PUBLIC HEALTHVICES _*VIRONMENTAL HEALTH DIVISIOR' 445 N SAN JOAQUIN, PHONE (209)468-3420 kp&' 3 P O BOX 2009, STOCBTON, CA 9520 PERMIT EXPIRES 1 YEAR FROM DATE ISt (Complete in Triplicate) ( f i MAR 2 4 Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein desc tL Thle application is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Re one of San Joaquin Count/y� -P7ublic Health Services. ENVIRO {�N ^MENTAL HlA� Job Address 1 T f S r r_�1rYL'�(�/] Av� City� Lot P ��I�yT�S��EBV� L Owner's NamesITS[10e_<_Lb. Address 1 6►' q SS blew Phone _I qui cgi6� '/'^ Contractor Address)'tuck"- 1 License No��9 447- Phone Z04-Q L10.3 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION Out of Service well PUMP INSTALLATION O SYSTEM REPAIR ❑ 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 fl Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation — Dia. of Well Casing f I Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_-_ _ Specifications 11 Public I:1 Other n Delta Depth of Grout Seal Type of Grout I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ Well Destruction Well Diameter Sealing Material i Depth Depth Filler Material i Depth �• TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION 11 (No septic system permitted if public sewer is !� available within 200 feet.) `I 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. O Method of Disposal Distance to nearest: Well Foundation Property Line —PA v I `T LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line NAR 4 fnn SEEPAGE PITS 11 Depth Size _ Number PURI In I,�.UIN COUNTY SUMPS LI Distance to nearest: Well Foundation Property Lin e VIR� IAL HEALTH VICES DISPOSAL PONDS O DIVISI 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: "1 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 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_callll for all required inspections. Complete drawing on reverse side. Signed X�� Title: � l/O0Sar Date: — FOR DEPARTMENT USE ONLY Application Accepted by Date L- Area O 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 0 Box 2009, Stkn, CA 95201 IEEENFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVX 11 ED BY DATE PERMIT N0. EH t420IREV.iinSi W D [0 C), O C7 l(/ () �� (� 33 5 EH t�2e ) \,(�)