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SAN JMQUIN COUNTY PUBLIC HEALTH SMRVICES r, ENVIRONMENTAL HEALTH DIVISION I / 445 N SAN JOAQUIN, PHONE (209)468-3420 I P O 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 coupliance with San Joaquin County Ordinance No. 5h9 and 1862 and the Rules and Regulations of San Joaquin County Public Health Services. (� Job Address Iqq `J ��V1 s 1` � City 11 Lot Size/Acreage [-- Owner's Name /�►.h e I Address �`�-L_Y -�-� - 4_ Phone Contractor l I 1 1 I/►� Address PSD, ,and- y� ' / f License No QQ-3 Phone - TYPE OF WELL/PUMP. NEW WELL ❑ WELL REPLACEMENT fl DESTRUCTION _ Out of Service Well PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well DISTANCE TO NEAREST: SEPTIC TANK 49/1Cf, SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS (l Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ( I Domestic/Private ❑ Gravel Pack O Tracy Type of Casing_ Specifications I"1 Public (1 Other (-1 Delta Depth of Grout Seal __ Type of Grout 11,61lation __ Approx. Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump r H.P. State Work Done Well Destruction Well Diameter Sealing Material i Depth Depth �� Filler Material i Depth TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if ptiblic sewer is available within 200 feet.) Installation will serve: Residence _ Commercial _ Other Number of living units: Number of bedrooms Character of toff to a depth of 3 feet: Water table depth \ Y SEPTIC TANK O Type/Mfg Capacity No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal Distance to nearest: Well Foundation Property Line LEACHING LINE ❑ No. 6 Length of lines Total length/size FILTER BED 0 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 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: "1 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, I shall employ persons subject to workman's compensa tion laws of California." The applicant mu if for all r qu. edi n ctions. Complete drawing on reverse side. �+ Signed !`I �/�/1/l7�Q�� Title: S 4 it-C-S Date: r (� e. F DEPAAtMtNT USE ONLY /1 / Application Accepted by C�,t.... �► , Date ea _AL1 Pit or Grout Inspection by Date _ Final Inspection b Deter Additional Comments: Applicant - Return all copies to: San Joaquin County Public Health Services Environmental Health Permit/Services 445 N San Joaquin_ x 2009, Stkn, CA 95201 ,NFO FEE MOUNT DUE AMOUNT REMITTED III CA RECEIVED BY D TE PERMIT'NO. . EH 14 24 111EV.i n s) 1-' '�--T � J , EN 14Ia W l-? z> t/1