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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 15 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 L.�Joaquin County Public Health Services. �Q//�� ,,••__ 7 , y [ City Lot Size/Acreage /t `� C"J Job Address Owner's Name ��/ r �� rAddress ` s Phone t Contractor - - _ S i z--Q� � -. �4ddress C � ��L License No, � r�(�/-7_Phone TYPE OF WELL/PUMP: NE WELL WELL REPLACEMENT G DESTRUCTION n Out of Service Well ❑ PUMP INSTALLAT ION Monitoring,Well SYSTEM REPAIR C OTHER Clf U DISTANCE TO NEAREST: SEPTIC TANKLINES DISPOSAL FLD. PROP, LINE 'S FOUNDATION _. '_ AGRICULTURE WELL :7 OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1-1 Industrial ❑ Open Bottom U Manteca Dia of Well Excavation Dia. of Well Casing ` Domestic/Private }Gravel Pack�, --CJ_Trac.y z „Type-of Cast g__ �C f Specifications Public Cl Other �I�� l Delta Depth of Grout Seal TypeIf of Grout r 11 Irrigation Approx.-Depth I I Eastern Syr ace Seal installed by P Repair Work Done L Type of Pump r ` H.P. — State Work Done Sealing Material 6 Depth Well Destruction ❑ Well Diameter 5 Depth Filler Material b Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I : iNo septic system permitted if public sewer is available within 100 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 ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ t Method of Disposal Z Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 8 Length of lines Total lengthisize FILTER BED D Distance to nearest: Well Foundation Property Line-� SEEPAGE PITS I I Depth Size Number _- SUMPS LI Distance to nearest: Well Foundation Prope+ty 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 foflowing:�'Lcertify 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 compensatio'n' laws of California." Contractor's hiring of sub-contracting signature certifies the folowing: "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-" IL k The applicant 8t'i afoP Lr 'uired irrtl—pdC ns Complete drawing on reverse siaa—. a + /j / Signed X Title's ` i7" -` _t Date: FOR DEPARTMENT-USE O .LY. -A Application Accepted by '" IDate �� 9 Area d Pit r Grou spection by Date eft lG Z '—Fidel Inspection by� Date �� l11q Z_ Additional Comments: Itf_f L6 111911 t ! t +---- Applicant--'-Return-ahlTcopl'e.s`•to:—'San Joaquin`County•"Publi'c"Heal'th'Sery-ices Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, •Stkn, CA 95201 -FEE AMOUNT DUE AMOUNT REWTTED CK' { " RECEIVED BY + ^DATE PERM7T'NO. INFO CASH y EH 13-24(REV.rinsr k1 ,�� 3 .. �' l G-2,q qz L EH 14-26 ...�.,... .. �..�..... ...�-..-.+— -.+—..�.----<-.------^--+•--��..�.:: -