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w' 7�. 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. ��p� Job Address 2 s ''`LL�&W CityL1AJ0aU• Lot Size/Acreage Owner's Name-VC— J Address �7'"�m� t +' 234 _ Phone .W 4S-00 .E. f�leCMov'T ! Contractor Address License Nt� �Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well ❑ ^� PUMP INSTALLATION P" 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 n Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Welt Casing P-fomestic/Private ❑ Gravel Pack7 El Tracy Type of Casing_, Specifications (') Public I-1 Other n Delta Depth of Grout Seal Type of Grout a I I Irrigation _.Approx. Depth I I Eastern Surface Segall Installed by Repair Work Done L7 Type of Pump H.P. ��JA State Work Done Well Destruction O Well Diameter Sealing Material & Depth AJ Depth Filler Material & Depth U&, TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIRIADDITION I I DESTRUCTION I I INo septic system permitted it public sewer is available within 200 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. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. A Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number f� SUMPS LI Distance to nearest: Well Foundation Property Line f 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 tJ 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." 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, 1 shall employ persons subject to workman's compensa- tion laws of California." The applicant muat call for all required inspect io Complete drawing on rexar;Q:9 ,Signed Title: /�- S,.L.�(�� Date: 2-�C��' i 2 l R EPARTMENT USE ONLY p Application Accepted by `v", Data �- l Area 02-111 Pit or Grout Inspection by Data 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 O Box 2009, Stkn, CA 95201 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE QPERMIT'No.d « EM 13-24 IREV.t/M5) [1. e O� `f] ' �r 3 EH 14.26 7�"' C.J f/� i