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. t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 9520 . PERMIT EXPIRES I 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 Service uw sl d • City Lot Size/Acreage J �r er Job Address - TXA No/"�e r�_ hi sem' Address �, Phone � Owner's Name _ w _ --Y_ ry Contractor �Addr�ess ��2 ! License No, p 3 PhoneTYPE OF WELL/PUMP: NELACEMEN'i- 7=_`_"`� DESTRUCTION i_l Out of Service Well ❑ PUMP INSTALLATION SYSTEM REPAIR ❑� OTHER © Monitoring Well ❑ .DISTANCE TO NEAREST: SEPTIC TANK �I ` SEWER LINES,, + DISPOSAL,FL PROP. LINE FOUNDATION _ AGRICULTURE WELL== OTHER WELL PITS/SUMPS f. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION.` L1 Indu tnai ❑ Open Bottom anteca Dia. of Well Excav tion Dia. of Well Casin omestic/Private ravel Pack ❑ Tracy Type of Casing C + OSpecifications ~ 1'1 Public 1-1 O_the� 11 Delta Depth of Grout Seal-� Type of Grout l I Irrigation IKp Depth l I Eastern Surface Soul Installed by `. Repair Work Done 0 Type of Pump H.P. State Work Done Well Destruction 0 Well Diameter Sealing Material A Depth / Depth Filler Material 6 Depth TYPE OF SEPTIC WORK: NEW INSTALLATION t I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public saws( is available within 200 feet.) `. d 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 Distance to nearest: Well Foundation 'Property Line LEACHING LINE Cl No. & Length of lines y Total length/size FILTER BED CI Distance to nearest: Well Foundation Property Line SEEPAGE PITS e 11 Depth Size Number SUMPS LI aDisfanca to nearest: Well Foundation Property Line DISPOSAL PONDS 'D 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 mariner as to become subject to workman's compensation laws of California." Contractor's%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 persovs subject to workman's compensa- tion laws of Caiiforriv' s, , ' The applicant moot call for all req ui iJnsp�ejtyionJs. Complete drawing on reverse ids. Signed X�{ " 1 '" Com— Title: /D'fJ�I" __ _ Date/ FO SPARENT U ONLY Application Accepted by DatAreal Pit (Grout napection by Date Final Inspection b Date/ Additional Comments: --• Appliteant '' Return all cWiesvto: San 'Joaquiri County Public. Health"ServicesJ� 'r__ 4�J `v� .0766 Environmental Health Permit/Services 495 N San Joaquin, P 0 Box 2009, Stkn, CA 95201p,�r �Fj'�� i1'��3� FE _ AMOUNT DUE— AMOUNT.REMITTED -CASHCK ' -RECEIVED BY DATE PERMIT'-NO, 01 : EH13.24IAEV.riX5) i '(� to—f-SA - 1 ^„� EH 14.20 �.J