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SAN 'ENVIRONMENTAL COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL HEALTH DIVISIOV" 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 Publicbealtb Services. Job Address _Lcoo CkL1 ?c s� City&L-p1 Lot Size/Acreage Owner's Name ST. 'lr05214 IS"i- 4 �Address IJ C-Au f=ng-A)l PPhone Contractor /E6��/y A ��r1jet� Address b No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ PUMP INSTALLATION_ ❑ SYSTEM REPAIR ❑ 0 T H E R,_l< Mo 'tori Well DISTANCE TO NEAREST: SEPTIC TANKrrJ" ' �� .�_ SEWER LINES ��DISPOSAL FLO. �1� PROP. LINE FOUNDATION �D , AGRICULTURE WELL _NA_.OTHER WELL.?� PITS/SUMPS J5 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n Industrial ❑ Open Bottom ❑ Manteca Dia. of Excavation 2 Dia. of Well Casing Domestic/Private ❑ Gravel Pack ❑ Tracy Type of sing IJP Specifications ('1 Public ,1 Cl Other nDelta Depth of Grout Seal ,�C� Type of Grout EAS C��E I I IrrigIc 0--1 V J _Approx. Depth X Eastern Surface Seal Installed by Repair Work Done U Type of Pump H.P. State Work Done _ \ Well Destruction ❑ Well Diameter Sealing Material i Depth Depth Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 I DESTRUCTION I I (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 O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT.❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS 11 Depth Size Number 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, 1 shall not �F 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, I shall employ persons subject to workman's compensa- tion laws of California." r The applicant st call for all requ- ins pec 'o s. to drawing on reverse side. Signed X Title: GA. %Z• fc, r0 3 Dater FOR DEPARTMENT USE ONLY Application Accepted by Date — Area Pit or Grout Inspection by ate Final Inspection by Date Additional Comments: 02 6'/0/ Applicant - Return all copies c: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 FEE INFO AMOUNT DUE � AMOUNT REMITTED CASH RECEIVED BY DATE n EH 13-24(REV.insi Q EM 1♦-2it) /D l y�14-25 (-J ((/ d `