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r SAN J%,AQUIN COUNTY PUBLIC HEALTH S,�tVICES ENVIRONMENTAL HEALTH DIVISION 445 N SAN JOAQUIN, PHONE (209)468-3420 P O BOX 2009, STOCKTON, CA 95201 PERMIT EXPIRES I YEAR FROM DATE ISSUID C(OPY (Complete in Triplicate) 4 i Application is hereby made,to San Joaquin County for a permit to construct and/or install the work herein described. This application Se made In Compliance with San Joaquin County Ordinance No. 549 and 2862 and the Rules and Regulations of San Joaquia County Public Health Servlcea. f Job Address 4C `* Jr. A 446 City t Size/Acreage OF Owner's Na Address d � - Phone ?<Conttactor 52 L Address License No. Phone TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT 171 DESTRUCTION 0 Out of Service Well 0 PUMP INSTAL LAT] �„ SYSTEM REP IS C] OTHER C] Monitoring Well. s DISTANCE TO NEAREST: SEPTIC TANKS SEWER LINES DISPOSAL FLO. PROP. LINE FOUNDATION+ AGRICULT ELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PA L EA CONSTRUCTION SPECIFICATIONS ❑ Indusfrial ❑ Open Bottom a ca Dia. of Well Excavation Dia. of Well Casing •-� C] Doi�stic/Private ❑ Gravel Pe ❑ Tracy Type of Casing Specifications I"1 Public C3 Other ❑ Datta th of Grout Seat Type of Grout I i Irrigation ` _ pprox. Depth i I Eastern Surface eu stalled by Repair Work Done U Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Nsterial i Depth TYPE OF SEPTIC WORK�V L I I REPAIR/ADOITION I I DESTRUCTION (No septic system permitted if public sewer is ailable within 200 feet.) �n Installation will serve. Reside e ti "EX N Number of living units: ' mrbberof roams vv I Character of soil to a depth o1 �t"a �� Water table depth SEPTIC TANK. M1O�r ff ►t Capacity No. Compartments PKG. TREATMENT PLT.L�y �vRr �5�i Method of Disposal i a J ��pp Distance o n'AAtest`a� �alIr^'Mundatian Property Line _ I LEACHING LINE ❑ No. 8 Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line i SEEPAGE PITS 11 Depth Size Numbar f SUMPS LI Distance to nearest: Well Foundation Property Line DISPOSAL PONDS ❑ 1-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 parson in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature certifies the fotlowing:"1 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 applican at call for all required inspection . Complete drawing wo�si x Signed Title: - Date. ` OR D PARTMENT USE ONLY3 J Application Accepted by Date ? Area .2 , ]� Ph or Grout inspection by Date Fine Inspection b Date Additional Comments. _ I Applicant - Return all copies'to: Son Joaquin County Public Health Services - Snvironmental Health Permit/Services _.;�• . ... 445 .N San Joaquin, P O Box 2009. Stkn,*'CA.95201FEE tirr• INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. EM113-24(REV.I/NS D , i` / �'O� t i