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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 and Regulations of San Joaquin County Public Health Services. j tee- �C Job Address DSO `/' ►��+ ~/�G�� —-City Lot Size/Acreage f Owner's Name Address 1 Phone Contractor Kea Ifi/� GQb ss Addressea ( I�� License No.W73X' Phone 37 4- () TYPE OF WELL/PUMP: NEW WELL 1j;_, WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well i=l PUMP IN 29"- SYSTEM REPAIR 71 OTHER ❑ Monitoring Well U Q h DISTANCE TO NEAREST: SEPTIC TANK :22:-_ ' -SEWER LINES DISPOSAL FLD. $_ PROP. LINE 1-0 FOUNDATION AGRICULTUREEWELL-- - OTHER WELL. PITS/SUMPS — INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS _Ij L} industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation '�-- Dia. of Well Casing 4 omestic/Private r Gravel Pack M Tracy Type of Casing_ Specifications F-Y V1 Public Ll Other n Delta Depth of Grout Seal �c� _ Type of Grout C� � t I Irrigation Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done L7 Type of Pump rt'f H.P. l — State Work Done _ A' S eC Well Destruction ❑ Well Diameter Sealing Material Depth Depth iFFiller-Matirial i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION i I DESTRUCTION I I (No septic system permitted it public sewer is available within 200 feet.l `�- installation will serve: Residence_ Commercial— Other Number of living units: Number of bedrooms �'- Cha utter of soil to a depth of 3 feet: v � - - Water-table depth, SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE Cl No. & Length of lines Total length/size FILTER BED n Distance to nearest: Wetl Foundation Property Line (� SEEPAGE PITS 11 Depth Size Number n E SUMPS Ll Distance to nearest: Well Foundation Property 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 ordinantes, 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 rnanner as tti become subject lo 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,'l shall employ persons subject to workman's compensa- tion laws of California." The applicant must II for all requir d inspections. Complete drawing on reverse side. ' Signed X Title: a �ti,jK ? Date: fi�fir~ � FOR DEPARTMENT USE ONLY /( Application Accepted by i�� Data � -- - Area aI Pit orro 1 Inspection bl Date _a l Final Inspections byto�-Z6�- j Additional Comments: - S �` ~ � �'' " 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 CK A RECEIVED BY DATE PERMIT'NO.- INFF,O++ CASH 2 . EH13.24{REV,t i n 51 w N PA) r dI / /�/� ��r' 6 1� �, �/ EH 14.28 ✓✓ J /