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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O 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. 5119 and 1862 and the Rules and Regulations of San Joaquin County Public Health 8e v ces. r Job Address 50 5 19 City Lot Size/Acreage Owner's Name P262n, C" Address Mqo�- A Phone Contract Address License No.3�� Phone-SlO� TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ID fF DESTRUCTION Irl Out of Service,well ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR.,❑ OTHER ❑ Monitoring Well ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES -•DISPOSAL FLD. PROP. LINE FOUNDATION. AGRICULTURE WELL. ' OTHER WELL PITSJSUMPS _ ,. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ( [� 0 Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing ' J fa Domestic/Private Ci Gravel Pack Cl Tracy Type of Casing= Specifications I'1 Public CI Other n Delta Depth of Grout Seal J Type of Grout I I Inigalion _.Approx. Depth 1 I Eastern Surface Seal installed by Repair Work Done U Type of Pump M.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material &•.Depth, Depth Filler Material &Depth TYPE OF SEPTIC WORK; NEW INSTALLATION I REPAIR/ DDITIONN DESTRUCTION I I INo-septic system,permitted it public sewer is o (.available within 200'feet.) Installation will serve: Residence P/Commercial— Other i iv I Number of living units: __L Number of rooms "k— Character of soil to a depth of 3 feet: r Water table depth + SEPTIC TANK Type/Mfg Cipacity--1-A00Na. Compartments PKG. TREATMENT PLT. ❑ / f Method ofe-Di�posal Distance to nearest: Well� Foundation Property Line I If / LEACHING UNE No. & Length of linea — Total length/size x / I FILTER BEI? n Distance to nearest: Well P 1+ Foundation 1D + Property Line ^ If e� SEEPAGE PITSDepth y Size Number SUMPS LI Distance to nearest: Well - DO+ /Foundation 10 t Property Line , '{ "'—a15POSA PONDS ❑� �.- ,�. �., .r 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." Contractors 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." I - 1. The app lican st caR I ulred inspections. Camptete drawing on re se side.,. Signed '�{� Title: f Date: • f z � i f FOR DEPARTMENT USE ONLY Application Accepted by Data 2 Area 60 r,Grout Inspection by� ate nal Inspection by "" /��'-^f�-�—Date_J_r 2 Additional Comments: 'J r P Applicant - Return all copies to: San Joaquin'County Public Health Services Environmental Health Permit/Services s 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEElINFO AMOUNT DUE AMOUNT REMITTED ASRECEIVED BY DATE PERMIT'NO. r . £H 13-21[REV. /n 5r EH 14•26