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� AN JOAQUIN COUNTY PU43LIC HEALTH SERVICESCe } ` C ENVIRONMENTAL HEALTH DIVISION Vis S 445 N SAN JOAQUIN, `PHONE (209)468-3420 l/ tel\ ` P O BOX 2009, STOCKTON, CA 95201 a W-1910- ,o� �j PERMIT EXPIRES 1 .YEAR FROM DATE ISSUED Q 'f ,�� (Complete in Triplicate) Application 1`e/hereby made to San Joaquln.County'for a permit to u construct and/or install the ork herein described. This application is made in compliance xith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Y Joaquin County Public Health Serviced. Job Address ` .... f r�` 1 �ltl/ '`� Citµ - `' - "/ '�ot Size/Acreage i Owner's Name Address �/ 1 r } Phone �/ ✓ �ftf r Contractor t.'. 1 /f.�r�l r. M/ -Address !'/ G �l ty� � Licgnse No. L .iri; u 'hone -;f rl y w TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENTX DESTRUCTION ❑ Out of Service Well PUMP INSTAL LATI yy SYSTEM REPAIR ❑ OTHER O Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK `y SEWER LINES. DISPOSAL FLD. PROP. LINEi' - FOUNDATION 1 AGRICULTURE WELL L OTHER WELLAE PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS E] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio - - - 1 Dia. of Well Casing r "Domestic/Private Pack O Tracy Type of Casing__ Specifications / I'I Public (1 Other n Delta Depthof Grout Seal ' Type Grout I I Irrigation .Approx. Depth/ I I Easter Suri c Seal Installed by Repair Work Done Type of Pump. } L"�> .t' •>• .P. r �' ' State Work Done f Sealing te'ial & Depth Well Destruction Well Diameter Depth �b72;- Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I .DESTRUCTION 11 (No septic system permitted if 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 iPKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE L1 No. & Length of lines, Total length/sjze _ FILTER BED CI Distance to nearest: Well Foundation Property Line I I SEEPAGE PITS 11 Depth Size — Number SUMPS LI 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 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." Contractor's hiring or sub-contraFting 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." The applicant must eijll for all'(soul d Inspections. Complete drawing on rove its C ` ' Aide. Signed Signed ltfe: ' Date: //, F R D ART ENT USE ONLY Application Accepted by - Date } V �` Area_ IX �_ Pit or Grout Inspection by AA Date //_ final Inspection by_ Data Additional Comments: 7V Applicant - Return all copies t San Joaquin County Public 'Health Services Environmental Healt'h`Permit/Services 445 N San Joaquin, P'O Box 2009, Stkn, CA 95201 CK NFO AMOUNT DUE AMOUNT REMITTED CASH ECEIVED BY DATE PERMIT'No. • EN 134v1{REV.1in�1 EH 11.26ZV - T,U�0 G n `� �. - r 7 l