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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 k PERMIT EXPIRES 1 YEAR FROM DATE ISSUED +' f (Complete in Triplicate) Application is hereby made to San Joaquin County for a permit to construct and/or install the work herein described. This j application is made in compliance vith San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. I Job Address t S^.S^Sr N• ptr IrH r��S AV is City S+OCW-70#4 Lot Size/Acre Q Q 4OO-pp- bo*7ftH�. (LRM b Z� `` �� S7" Owner's Name �fe nos Address e Z (0 80 Z0Z Phone � CPZ. Liz BLMil DRtVI e- 57 'Contractor �iQ�E4C► fF-1LL 1-"41% Address P Ac '"COcA- 9 Lf Er-.3 License License NON&0(2 S^ &80•, tf t{Z TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION ❑ Out of Service Well 0 PUMP INSTALLATION f) SYSTEM R�PAIR Ll OTHER ❑ Monitoring Well X DISTANCE TO NEAREST: SEPTIC TANK1.> s0` SEWER LINES �a DISPOSAL FLD. N A PROP. LINE "- 3S•e FOUNDATION AGRICULTURE WELL MIA_ OTHER WELL YA PITS/SUMPS T sb` INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom If Manteca Dia. Of Well Excavation Z �• Dia. of Well Casing E-I Domestic/Private El Gravel Pack ❑ Tracy Type of Casing_ PV L I'] Public p Specifications �H O C] Ot er 11 (1 Delta Depth of Grout Seal Z p r Type of Grout AOjZTCA�k•lb Co , # I Irrigation 3,�-Approx, Depth I I Eastern Surface Sec11 Installed by b L.( 1 it.{ Repair Work Done U Type of Pump -N m-i Lf, H,P. State Work Done T Well Destruction ❑ Well Diameter ' Sealing Material & Depth Depth j Filler Material & Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDITION I I DESTRUCTION I i IND septic system permitted if public se4-1 wer is Installation will serve: Residence— Commercial available within 200 feet.) Other Number of living unite: Number of bedrooms Character of soil to a depth of 3 feet: SEPTIC TANK ❑ T Water table depth ype/Mfg 1 Capacity No. Compartments PKG. TREATMENT PLT. ❑ 1. t Method of Disposal Distance to nearest: Well Foundation Property Lina �. `' LEACHING LINE 0 No. & Lengtti'of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation 1 Property Line SEEPAGE PITS 11 Depth f Size Number SUMPS L3 Distance to nearest: Well Foundation DISPOSAL PONDS 111 Property Line i I hereby certify that 1 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 became 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 persons subject to workman's compensa- tion laws of California." r The applica usI call for II required inspections. Complete drawing on reverse side. Signed X t 1- Title: �ifls It f � 42 • Date: _ , j R DEP- RTMENT USE ONLY Application Accepted by 3 Date74 Area Pit of Grout Inspection by Date 2. 7 Final Inspection by Date Additional Comments: j w Applicant - Return all copies to: San Joaquin, County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Hoic 2009, Stkn, CA 95201 INFO AMOUNT DUE 'AMOUNT REMITTED CK CASH RECEIVED 8Y DATE PERMIT'ND. J EH 1IrtEV, EH 4-n riHsy 07 1 0 O I